Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient hospital stay.
The insurer denied the inpatient hospital stay as not medically necessary.
The health plan determination is overturned in whole.

This was a young patient at the time of service with a past medical history (PMH) of ulcerative colitis on mesalamine who presented with chief complaint of 10-day history of diarrhea and abdominal pain. As per patient's parents, patient started having intermittent diffuse abdominal pain, sometimes brought on with meals. The day prior to admission, the pain became constant. Patient initially had loose brown stools, about 6-7 episodes per day. The patient reports one episode of having loose stool with pink-red appearance, occurred the night prior to admission. The patient also reports the last bowel movements, on day of admission, have been watery diarrhea. The patient reports this presentation is similar to prior ulcerative colitis (UC) flares. Patient's last meal was on morning of admission,  had pancakes and sausage. Patient has missed school (about 1.5 weeks) because of these symptoms. Patient presented to the emergency room (ER) for similar symptoms 3 days prior and as per the gastrointestinal (GI) note: Plan to send stool studies, is well appearing, stable with reassuring labs and has not had any further diarrhea, will plan for discharge to home as this is likely a viral illness. The patient was discharged.
The Parents report the patient worsened over the last two days and started having worsened diarrhea and stools became bloody. Patient has been having nighttime awakenings for stool and abdominal pain has worsened. Patient reports fever 2 weeks prior to presentation with sore throat and body aches. Workup was negative. At this time patient denies fever, nausea, vomiting, congestion, cough, rhinorrhea, dysuria, or decreased by mouth (PO) intake or urine output. Patient presented to the ED for these symptoms and GI was consulted. . Labs revealed normal electrolytes, lipase, white count, and C-reactive protein (CRP). The erythrocyte sedimentation rate (ESR) was elevated. Stool guaiac was positive. Abdominal X-ray revealed left colon collapsed and exhibiting wall thickening consistent with colitis. Patient was admitted to the pediatric floor in stable condition for further management and suspected ulcerative colitis (UC) flare vs. infection. Stool resulted positive for C. Diff and the patient was started on a 10 day course of PO vancomycin. Clear liquid diet was advanced per pediatric GI team. Recommendation was if the patient tolerated an advanced diet the patient could be discharged to complete 14 days of PO Vancomycin. As such the patient was medically cleared for discharge home with a diagnosis of colitis due to C. Diff. 

The requested health service/treatment of inpatient stay is medically necessary for this patient. This patient presented with worsening of his diarrhea and abdominal pain as well as stools progressing to bloody in nature. Given the underlying ulcerative colitis, admission for inpatient medical management and monitoring for complications of  inflammatory bowel disease would be acceptable. This patient had presented to the ER 3 days prior, was evaluated and treated as an outpatient. The symptoms escalated and  failed outpatient management. The patient demonstrated intermittent tachycardia, and was having 6-7 stools/day. An x-ray taken revealed signs of active colitis as well as physical finding of diffuse abdominal tenderness as well as distention. Evaluation by the gastroenterologist also recommended admission pending further workup as an inpatient to formulate a treatment plan and determine if  symptoms were due to an infectious cause vs. ulcerative colitis flare. Patient was found to be C. difficile positive and sent home on oral Vancomycin after improvement in symptoms. Given history of underlying ulcerative colitis, and worsening after outpatient management, inpatient admission for medical management and monitoring for complications of inflammatory bowel disease would be medically necessary to safely and adequately monitor and care for this patient.