Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic Infection
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient is a female with a history of asthma, eczema, ADHD (attention deficit hyperactivity disorder), bipolar disorder, schizophrenia, multiple STIs (sexually transmitted infections), and a history of sex work. She was evaluated in the ED (emergency department).  She presented with pelvic pain.  No fever, nausea or vomiting was noted.  She had recently been admitted for this same issue and was given antibiotics (doxycyline and flagyl), but had not taken them.  She had also been recently treated for asthma exacerbation.

The patient was evaluated and was found to be hemodynamically stable.  No fever was noted.  Her exam revealed lower abdominal discomfort and cervical motion tenderness.  Her white blood cell count was elevated.  She was given an IV (intravenous) and started on cefoxitin.  She was given oral doxycycline and flagyl.  She was combative with staff and refused her medications.  She was then given an IV (intravenous) dose of azithromycin and toradol.  Her pain improved.  She continued to be combative.  She was discharged home with outpatient follow up.

Yes, the Inpatient admission was medically necessary.
According to Workowski, most women with PID (pelvic inflammatory disease) can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include the following:

Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain),
Complicated PID (pelvic inflammatory disease) with pelvic abscess (including tubo-ovarian abscess),
Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess,
Inability to take oral medications due to nausea and vomiting,
Pregnancy,
Lack of response or tolerance to oral medications, and
Concern for non-adherence to therapy.

There has been a persistent trend towards outpatient treatment of PID (pelvic inflammatory disease) with only the minority of women being hospitalized. Support for outpatient therapy for mild or moderate PID (pelvic inflammatory disease) comes from the Pelvic Inflammation Disease Evaluation Clinical Health trial (ie, 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 (eg, ectopic pregnancy, chronic pelvic pain) were similar between the two groups.

In review of the medical record, this patient has noncompliance issues.  She had been treated previously, but she continued to be non-compliant with her medications.  Although she was hemodynamically stable, without abscess, or need for surgical intervention, without proper treatment, the infection could lead to these processes.  Noncompliance is one indication for hospital admission.  Therefore, this hospitalization was warranted to ensure that she had the appropriate treatment to prevent worsening pelvic inflammatory disease.