Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Inflammatory Disease (PID). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female who presented to the emergency department with vaginal bleeding and abdominal pain. She rated her pain 10 out of 10. She had nausea but no vomiting. She was evaluated with exam and blood work. She had urine and genital cultures. Her exam revealed diffuse abdominal pain. The patient had an elevated white blood cell count. She had pelvic ultrasound revealing a 2.5-centimeter hypoechoic mass next to the right ovary. Computed tomography (CT) scan revealed appendiceal wall hyperemia. Both general surgery and gynecology were consulted. General surgery did not feel it was appendicitis and signed off. The patient was admitted to the gynecology service with the diagnosis of pelvic inflammatory disease. She had cervical motion tenderness. She had a fever to 100.9. She was given intravenous access. She was started on intravenous Flagyl, doxycycline, and ceftriaxone. The patient was given intravenous morphine, Toradol, and Tylenol. She was also given antiemetics. She was not pregnant. 

By day #2, the patient was feeling better. She was afebrile with stable vital signs and her pain was a 1 out of 10. She was continued on intravenous antibiotics until intravenous access was lost. After 24 hours she was transitioned to oral antibiotics. She tolerated them fine and remained afebrile. Her blood work improved. The next day the patient was discharged home on oral antibiotics for 14 days. She was scheduled for outpatient follow up. The inpatient admission was denied as not medically necessary. This is being appealed. 

The proposed treatment was not medically necessary. 

According to Workowski, most women with pelvic inflammatory disease can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include: 
- Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain) 
- Complicated pelvic inflammatory disease with pelvic abscess (including tubo-ovarian abscess) 
- Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess 
- Inability to take oral medications due to nausea and vomiting 
- Pregnancy 
- Lack of response or tolerance to oral medications 
- Concern for non-adherence to therapy. 

There has been a persistent trend towards outpatient treatment of pelvic inflammatory disease with only the minority of women being hospitalized. Support for outpatient therapy for mild or moderate pelvic inflammatory disease comes from the Pelvic Inflammation Disease Evaluation Clinical Health trial (i.e., PEACH trial). In that trial, 831 women with lower abdominal pain, uterine or adnexal tenderness, and mucopurulent cervicitis or untreated gonococcal or chlamydial infection were randomly assigned to inpatient therapy with intravenous cefoxitin for at least 48 hours plus doxycycline or outpatient therapy with a single intramuscular dose of cefoxitin with probenecid plus doxycycline. Short-term clinical and microbiologic outcomes and long-term reproductive outcomes (e.g., ectopic pregnancy, chronic pelvic pain) were similar between the two groups. 

In review of the medical record, the patient had severe abdominal pain, so it did qualify for outpatient treatment for pelvic inflammatory disease. She did require a hospital setting. 

However, the patient did not have evidence of a tubo-ovarian abscess, appendicitis, need for surgical intervention, or high fevers. The care she received did not require an acute inpatient level of care. She did not require greater than 24 hours of intravenous antibiotics and her clinical picture improved within 24 hours. Therefore, the same outcome could have been achieved at a lower level of care such as observation. The inpatient hospital stay was not medically necessary.