Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis
 
Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial is upheld. 

This patient is a female who presented to an Emergency Room (ER) with complains of right lower quadrant (RLQ) abdominal pain. The patient presented to the ER with symptoms suggesting appendicitis. The symptoms included RLQ abdominal pain, nausea, and a single episode of emesis. The ER work-up focused on evaluation of possible appendicitis. The white blood count was minimally elevated (13.05), but with a normal differential count (13% polymorphonuclears [PMNs]).  A computed tomography (CT) scan excluded the presence of appendicitis. The appendix was visualized to be normal and showed some minimal evidence of wall thickening of the rectosigmoid colon (remote from the patient's site of pain) attributable to normal peristalsis or to "mild colitis." Clinical correlation was recommended (as this is remote from the patient symptoms, the clinical correlation for "mild colitis" does not support this diagnosis). A pelvic ultrasound was performed in view of the well-known propensity of pelvic pathology in females of this age group to "mimic" symptoms of appendicitis.

The pelvic ultrasound and CT scan each showed no evidence of pelvic pathology. This testing was completed after midnight. The patient was admitted to the hospital and discharged later that day with a diagnosis of "colitis." The patient's presenting symptoms warranted a careful evaluation for appendicitis. This was completed in the Emergency Room (ER). When it became apparent that appendicitis was absent, an evaluation for pelvic pathology known to "mimic" appendicitis was warranted. This too was carried out in the ER. Following the ER evaluation, it was clear that the patient did not have any acute abdominal pathology. While a CT scan had suggested "mild colitis" in the event of clinical correlation, there was no such clinical correlation as the patient's symptoms were remote from the region of minimal abnormality (probably normal peristalsis per the CT report) seen on the CT scan. At this point, inpatient care was not required. A discharge from the ER with outpatient follow-up would have posed no risk to the patient.      

According to Gans, S. L., et al. (2015), "Uniform terminology is needed in patients with acute abdominal pain to avoid difficulty in interpretation and ease comparison of findings between studies. We propose the use of the following definition for acute abdominal pain: pain of nontraumatic origin with a maximum duration of 5 days. Clinical diagnosis: Clinical evaluation is advised to differentiate between urgent and nonurgent causes. The diagnostic accuracy of clinical assessment is insufficient to identify the correct diagnosis but can discriminate between urgent and nonurgent causes. Patients suspected of nonurgent diagnoses can safely be reevaluated the next day"

Following the ER evaluation, it was clear that the patient did not have any acute abdominal pathology. While a CT scan had suggested "mild colitis" in the event of clinical correlation, there was no such clinical correlation as the patient's symptoms were remote from the region of minimal abnormality (probably normal peristalsis per CT report) seen on the CT scan. At this point, inpatient care was not required. Discharge from the ER with outpatient follow-up would have posed no risk to the patient. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.