Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain, fever, chills, nausea, vomiting, low back pain, and urinary frequency.
Treatment: Inpatient admission.

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

The patient is a female who presented with ten out of ten (10/10) abdominal pain, fever, chills, nausea, vomiting, low back pain, and urinary frequency.  She has a history of anemia and hydrosalpinx from syphilis.  

The patient's examination revealed an acute abdomen with guarding and rebound, adnexal tenderness, and abnormal vaginal discharge.  She was febrile and tachycardic.  Her blood work revealed leukocytosis of 16.4 and anemia.  She had an ultrasound, which revealed a persistent hydrosalpinx and enlarged fibroids.  She was diagnosed with pelvic inflammatory disease and was started on intravenous (IV) clindamycin and intravenous gentamicin.  She was given Tylenol and ibuprofen for pain.  By the next day, her pain had improved to a five out of ten (5/10).  She was continued on the intravenous antibiotics.  Day 3, the patient was feeling much better.  Her white blood cell count normalized.  She was discharged home to finish a 14-day course of antibiotics.

Yes, the inpatient admission was 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:  1) Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain), 2) Complicated pelvic inflammaotry disease (PID) with pelvic abscess (including tubo-ovarian abscess), 3) Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess, 4) Inability to take oral medications due to nausea and vomiting, 5)  Pregnancy, 6) Lack of response or tolerance to oral medications, or 7) 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 comes from the Pelvic Inflammation Disease Evaluation Clinical Health trial (i.e., 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 (e.g., ectopic pregnancy, chronic pelvic pain) were similar between the two groups.

In review of the medical record, the patient met indications for admission.  She had a severe clinical picture with fever, nausea, and vomiting.  She had severe pain ranked ten out of ten.  The literature supports that this is a clinical scenario where admission is warranted.  Therefore, the admission was medically necessary, as it was the accepted standard of treatment, appropriate for the clinical scenario, and was not for convenience.

In this clinical scenario, the admission was warranted given the severity of illness.