Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male with a past medical history remarkable for alcohol abuse, and cellulitis, who was admitted for severe back and left lower abdominal pain. Review of system was negative for additional symptoms. The patient was afebrile (Temp of 36.8). The patient was described as well-developed and no acute distress. His blood pressure was 146/81, pulse rate was 93, respiratory rate was 20, and oxygen saturation was 98-100% on room air. The physical examination was remarkable for left lower quadrant abdominal tenderness. 
His laboratory evaluation demonstrated a sodium of 133, potassium of 3.5, chloride of 99, carbon dioxide (CO2) of 21, blood urea nitrogen (BUN) of 5, creatinine of 0.63, glucose of 86, white blood cell count (WBC) of 6.3, hemoglobin (Hgb) of 13.9, hematocrit (Hct) of 40.6, and platelets were 91. A computed tomography (CT) scan of the abdomen and pelvis revealed scattered colonic diverticula with evidence of thickening of the distal descending colon with surrounding fat stranding suggestive of diverticulitis. The magnetic resonance imaging (MRI) of the spine showed multilevel degenerative changes of the lumbar spine with mild to moderate canal narrowing of lumbar (L)4-5 and L5-sacral (S)1. 
The patient was admitted for acute diverticulitis. The patient was treated with intravenous (IV) fluids, ciprofloxacin and Flagyl. The patient was also monitored on Clinical Institute Withdrawal Assessment (CIWA) protocol for alcohol withdrawal symptoms. The patient was noted to have thrombocytopenia which was thought to be related to alcohol use. The hospital course was notable for findings of 4.2-centimeter (cm) lung mass for which it was recommended that the patient follow up as outpatient. The patient had diarrhea and difficulty walking. The patient's abdominal pain and diarrhea improved. Hyponatremia, hypomagnesemia, and hypophosphatemia improved. The patient's diet was advanced, and the patient was subsequently stable for discharge with outpatient follow up. 

At issue is the medical necessity of Inpatient Stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. 

The patient was admitted for acute uncomplicated diverticulitis without signs and symptoms of sepsis or systemic inflammatory response syndrome (SIRS). In those with minimal symptoms, outpatient management with or without oral antibiotics to cover colonic flora (including gram negative rods and anaerobes) is often sufficient. Patients with fever, systemic symptoms, or intolerance to oral intake, inpatient treatment with intravenous antibiotics and a short period of bowel rest may be appropriate. Inpatient admission may be necessary to assess clinical improvement to avoid complications such as abscess and intestinal perforation. In this case, the patient had no leukocytosis or fever, no clear documentation of prolonged intolerance to oral intake, he was hemodynamically stable, and he did not have worsening signs of sepsis or complications. Furthermore, the patient was not immunocompromised or had risk factors for treatment failure or complications. The patient did not have radiographic findings of abscess or perforation which represent features of complicated diverticulitis. In patients with acute uncomplicated diverticulitis, hospitalization should be considered if patients have signs of peritonitis or if there is suspicion of complicated diverticulitis, or difficulty with oral food intake. In this case, the patient did not have the aforementioned clinical signs. 
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.