Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who presented to the Emergency Room with complaints of a one day history of abdominal pain with associated nausea, vomiting and diarrhea. He had been initially diagnosed with diverticulitis which was treated at that time with antibiotics and a laparoscopic washout. The patient has experienced multiple recurrences following his initial diagnosis. He admits to being less than faithful in following the care plan. 

In the Emergency Room he was noted to be afebrile with stable vital signs. Physical Exam documents abdominal tenderness in the left lower quadrant (LLQ) with rebound.  Laboratory studies revealed a white blood cell (WBC) count of 9.3 without a shift and hemoglobin (Hgb) of 12.3. He was admitted to acute inpatient status on the surgical service and started on a clear liquid diet, intravenous (IV) fluids and Cipro and Flagyl.  A computed tomography (CT) scan done in the Emergency Department showed an area of diverticulitis similar to and unchanged from that seen on his prior scan. There was no drainable fluid collection present. 

Following admission, the patient remained afebrile with stable vital signs. A repeat complete blood count (CBC) showed a white blood cell (WBC) count of 6.6 and hemoglobin (HGB) of 11.9  with a subsequent test on the 28th showing a white blood cell (WBC) count of 4.1 and hemoglobin (Hgb) of 11.3.  By the following day, the patient's symptoms had resolved and he was discharges home on a ten day course of Augmentin. 

In its Final Adverse Determination Letter, the plan denied the hospitalization as not medically necessary stating that based on the medical records the patient could have managed in observational status and did not meet the requirements for hospital admission.  The providers appeal cites both Milliman Care Guidelines (MCG) and Interqual guidelines for acute diverticulitis and notes that the admission decision was based on real-time evaluation of the patient by the treating Practitioner. 

No, the proposed inpatient admission was not medically necessary. 

The patient's diagnosis is chronic recurrent uncomplicated diverticulitis.  He presented to the Emergency Room with a one day history of recurrent symptoms. On exam, he was documented to have some discomfort in the lower left abdomen but was also noted to be afebrile with a normal blood pressure and pulse. His white blood cell (WBC) count was normal and did not show a left shift. A computed tomography (CT) scan was ordered but not completed or reviewed by the treating practitioner prior to the admission decision being made. When completed, it was essentially unchanged from his prior scan and revealed no acute changes or worsening of his condition. He promptly responded to a course of intravenous (IV) fluids and antibiotics with a complete resolution of his symptoms and was discharged from the hospital within 48 hours of admission. 

The medical record fails to substantiate the need for acute patient care or meet the criteria for acute diverticulitis cited in the Provider's Appeal Letter. The patient's evaluation and treatment could have been managed in a observational setting. The denial is, therefore, upheld. 

The medical record clearly reflects that the diagnostic and therapeutic care rendered to the patient could have been provided in an observational setting and did not rise to the level requiring acute in-patient care. The health plan correctly determined this and denied the proposed treatment as not medically necessary.  By doing so, the health plan evidenced sound medical judgement and acted in the best interest of the patient.