Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with a medical history of hyperlipidemia, hypothyroidism, pneumonia, and cholecystectomy. She presented to the emergency department with fever, abdominal pain, nausea, vomiting, and diarrhea for three days. She had been to urgent care and started Imodium without improvement. She traveled out of the country the week prior. Her vital signs were notable for tachycardia with a pulse rate of 102 beats per minute. The physical examination was notable for a soft, nontender, nondistended abdomen. The laboratory studies (labs) showed unremarkable complete blood count and low potassium of 3.3.
The computed tomography scan of the abdomen and pelvis showed mild to moderate nonspecific cecitis/pancolitis with inflammatory and/or infectious etiologies to be considered. She was treated with intravenous fluids, Ketorolac, Ondansetron, and Morphine; she was started on Ciprofloxacin and Metronidazole. A gastroenterology consultation recommended stool gastrointestinal pathogen panel, empiric treatment with antibiotics, and supportive care. The gastrointestinal pathogen panel was positive for Salmonella. She had continued nausea and diarrhea.
The labs showed a low white blood cell count of 4.3 and an unremarkable comprehensive metabolic panel. She felt better, with less diarrhea; she was tolerating a regular diet. The labs showed a low white blood cell count of 4.4, a normal hemoglobin with low hematocrit of 32.6 percent (%), and an unremarkable comprehensive metabolic panel. She had no complaints, and her diarrhea was improving. She was discharged with a plan for primary care and gastroenterology follow-up.

The inpatient level of care is not supported as medically necessary. The patient presented with abdominal pain and fever, with finding of Salmonella on stool pathogen testing. She was appropriately maintained on antibiotic therapy with advancement of diet as tolerated.[1-4] However, there was no hemodynamic instability (such as hypotension), gastrointestinal bleeding, severe diarrhea, or other severe complications of infectious colitis. No other cause for colitis, such as Crohn's disease or Ulcerative Colitis, was documented.[5,6] The care provided, including monitoring, labs, gastroenterology consultation, and empiric antibiotic therapy, could have been provided without the inpatient level of care, at an alternate level of care. 

Per the Milliman Care Guidelines for Gastroenteritis, the inpatient level of care is not supported:
Admission is indicated for 1 or more of the following:
Suspected severe infection (e.g., bloody diarrhea)
(NOT MET)
Severe abdominal pain
(NOT MET)
Peritoneal signs
(NOT MET)
Toxic megacolon
(NOT MET)
Hemodynamic instability
(NOT MET)
Vomiting that is severe or persistent
(NOT MET)
Dehydration that is severe or persistent
(NOT MET)
Electrolyte or metabolic abnormality that is severe or persists despite observation care (e.g., acidosis, alkalosis, hyponatremia, hypernatremia)
(NOT MET)
Hemolytic uremic syndrome
(NOT MET)
Inability to maintain oral hydration (e.g., needs intravenous (IV) fluid support) that persists after observation care
(NOT MET).
 
The health plan's determination of medical necessity is upheld in whole.