Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is overturned

The medical records indicate the patient presented to the Emergency Department (ED) with gradually worsening left lower quadrant abdominal pain, for one (1) week. The patient complained of diarrhea with blood and reported that they took "one old pill" of doxycycline, which they said helped with the pain. The patient initially went to the Urgent Care, but was "instructed to come to the ED for further evaluation."

On presentation, the patient was noted to have tachycardia with a heart murmur. A physical examination revealed rebound tenderness and slight distention at the left lower quadrant. The patient's laboratory values revealed leukocytosis and an elevated lactate level. A computerized tomography (CT) scan of the abdomen and pelvis revealed an uncomplicated sigmoid diverticulitis. 

The patient was initially treated with intravenous (IV) fluids, analgesics, anti-emetics and antibiotics.

It was decided that the patient should be admitted. During the admission the patient received IV fluids and antibiotics.  The patient was admitted with tachycardia with a previously undiagnosed heart murmur along with an elevated lactate level. 

According to the hospital note, while the patient was treated for "uncomplicated sigmoid diverticulitis" they did have a white blood cell (WBC) count of 18 and elevated lactate. Along with the patient's "leukocytosis with fever" the inpatient hospital stay was medically necessary for this patient. 

"Inpatient management of diverticulitis requires intravenous antibiotics, intravenous fluids, and pain management. Again, antibiotics should cover gram-negative rods and anaerobes and be given for three to 5 days before switching to oral antibiotics for a ten to 14-day course. Bowel rest is preferred in patients requiring inpatient admission. Typically, defervescence and improvement in leukocytosis should be observed for two to four days of hospitalization, if not an alternative diagnosis or complications should be suspected. Prompt surgical evaluation should be considered.

About 15% patients with acute diverticulitis develop an abscess, specifically pericolonic and intra-mesenteric. Clinically, abscess formation should be suspected if fever and leukocytosis do not subside despite adequate intravenous (IV) antibiotics. On physical exam, a tender abdomen and tender mass suggest possible abscess formation. Abscesses that are less than 2 centimeters (cm) to 3 cm can be treated conservatively with IV antibiotics. Large abscesses should be drained percutaneously with CT guidance.

Fistula formation is another complication of acute diverticulitis. It is reported that less than 5% develops fistula; however, it has been found in about 20% of patients who undergo surgery for diverticulitis. The most common fistula is colovesicular fistula which occurs in about 65% of cases. Fecaluria is pathognomonic for colovesicular fistula. Surgical repair of the fistula with primary anastomosis is the treatment of choice. Colovaginal, coloenteric, colouterine, colourethral, and colocutaneous are other possible fistulae seen in acute complicated diverticulitis.

Partial bowel obstruction or pseudo-obstruction due to colonic ileus can occur as well, which can be managed conservatively. Complete bowel obstruction is rare in acute diverticulitis. Free perforation, if it occurs, should be managed surgically" (Linzay, C. D., & Pandit, S. 2023). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.