Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Occasional Painful Urination
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female who presented to the emergency department (ED) with abdominal/pelvic pain and painful urination.  The abdominal pain has been off and on since February.  She was seen in the emergency department (ED) on several occasions and given antibiotics for urinary tract infections.  She was seen six days prior to admission and treated for gonorrhea and chlamydia with intramuscular (IM) ceftriaxone and two pills of azithromycin.  She was also sent home with ciprofloxacin.  

The patient's evaluation in the emergency department (ED) revealed abdominal pain, cervical motion tenderness, vaginal discharge, and adnexal tenderness.  Blood work revealed microcytic anemia and normal white blood cell count.  She was afebrile.  There was no vomiting.  Her pain was minimal and controlled with Motrin.  She had an ultrasound revealing a 2.3 centimeter (cm) ovarian cyst.  She had a urinalysis which revealed group B streptococcus (GBS).  She was given intravenous (IV) cefoxitin and oral doxycycline.  Repeat exam had improved and she was discharged home to finish a 14 day course of doxycycline and seven days of amoxicillin.

No, the proposed inpatient admission was not medically necessary.
According to Workowski, most women with pelvic inflammatory disease (PID) 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 (PID) 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 (PID) with only the minority of women being hospitalized. Support for outpatient therapy for mild or moderate pelvic inflammatory disease (PID) comes from the Pelvic Inflammation Disease Evaluation Clinical Health trial (ie, 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 (eg, ectopic pregnancy, chronic pelvic pain) were similar between the two groups.

In review of the medical record, the patient had off and on abdominal pain and abnormal vaginal discharge since February.  She had been treated with oral antibiotics.  She was also seen six days prior and given a shot of ceftriaxone and two pills of azithromycin without improvement.  

The patient presented to the emergency department (ED) again but was afebrile, without nausea or vomiting, and no severe pain.  Workup revealed normal white blood cell count, abnormal urinalysis, and a right ovarian cyst but no abscess.  Given she was afebrile without a white blood cell count or tubo-ovarian abscess, she would have been a candidate for outpatient treatment of pelvic inflammatory disease (PID).  The prior treatments were for gonorrhea and chlamydia but not for pelvic inflammatory disease.  Therefore the acute inpatient admission was not warranted.  The same outcome could have been achieved at a lower level of care.

The evidence reveals that outcomes are the same when the correct outpatient medications are used for the treatment of pelvic inflammatory disease (PID).