Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

At issue is a denial of coverage for full hospital admission. The patient has a history (hx) of diverticulitis and rheumatoid arthritis. The patient presented to the Emergency Department (ED) with abdominal (abd) pain. The patient was admitted with acute diverticulitis, sigmoid diverticulitis, leukocytosis, fever and tachycardia. The patient had a gastrointestinal (GI) consult, continuous intravenous (IV) fluids and intravenous ceftriaxone. When the patient was stable the patient was discharged to follow up with GI (gastrointestinal specialty physician). There was a notation that the patient was deemed to be immunocompromised. The treating provider is requesting plan approval for full hospital admission. 

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such the care could have been rendered at a lesser level. 

Peer reviewed literature does not mandate a full acute hospitalization for the provision of supportive care in a clinically stable patient who has an uncomplicated diverticulitis attack without abscess. 

"Acute diverticulitis is inflammation of a diverticulum, a sac-like protrusion from the colon wall, due to micro-perforation. Diverticulitis presents in 10% to 25% of patients with diverticulosis. In the past, diverticulitis was treated surgically, however it is now a medically-managed entity, even in its most acute phase." (Linzay, et al., 2022). 

"Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review." (Rezapour, et al., 2018). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.