Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sigmoid colitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient has  a diagnosis of  end stage renal disease with bilateral kidney transplant and lupus. The patient presented to his primary provider with complaints of not feeling well. The patient was found to have an elevated creatinine. The patient was directed to the emergency department. The patient's creatinine had risen from 1.1 to 1.66. An acute sigmoid colitis from diverticulitis was noted. The patient received intravenous (IV) antibiotics and supportive care. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, severe electrolyte dyscrasias, hemodynamic changes, or renal abnormalities. There is a lack of documentation for a need for nothing by mouth (NPO) status, invasive surgery, invasive monitoring or treatments, nor any other indication for an acute admission.  

"More than 500,000 people in the United States live with end-stage renal disease (ESRD). The development of chronic kidney disease (CKD) and its progression to this terminal disease remains a significant cause of reduced quality of life and premature mortality. Chronic kidney disease (CKD) is a debilitating disease, and standards of medical care involve aggressive monitoring for signs of disease progression and early referral to specialists for dialysis or possible renal transplant. The Kidney Disease Improving Global Outcomes (KDIGO) foundation guidelines define CKD using kidney damage markers, specifically markers that determine proteinuria and glomerular filtration rate. By definition, the presence of both factors (glomerular filtration rate [GFR] less than 60  and albumin greater than 30) along with abnormalities of kidney structure or function for greater than three months signifies chronic kidney disease. End-stage renal disease is defined as a GFR of less than 15." (Hashmi, M.F., Benjamin, O., Lappin, S.L. 2023).

"Diverticulitis has increased in incidence over the past few decades, becoming a major healthcare burden for Western countries.[1] In the United States, acute diverticulitis results in nearly 200,000 hospital admissions and $2.2 billion in health care costs per year.] Although the prevalence of the disease increases with age, younger adults may also develop the diverticular disease. In fact, for some time, it was thought that younger and male patients were more likely to experience a more aggressive form of diverticulitis with an increased complication rate and higher recurrence.

However, recent studies have challenged this concept. Environmental and genetic risk factors result in diverticular disease development, although good quality evidence for many of these factors remains insufficient. Most cases of diverticulitis undergo successful management in the outpatient setting with oral antibiotics and temporary dietary restrictions. The decision to perform elective sigmoid colectomy in patients that recover from uncomplicated diverticulitis is controversial and requires case-by-case consideration. Surgical treatment is the recommendation in cases of complicated diverticulitis." (Carr, S., Velasco, A.L. 2022).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.