Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This case involves a patient who presented to the emergency department with complaints of abdominal pain.  The documentation does indicate she has a past medical history of diverticulitis.  She indicated she has pain that is similar to a prior episode of diverticulitis.  She stated she was allergic to most oral antibiotics, so her physician advised her to be seen in the emergency department.  The physical examination revealed a temperature of 97.8 degrees.  Her heart rate was 105 beats per minute and blood pressure was 157/107.  She was noted to be in mild distress on physical examination.  She was alert and oriented.  The recommendation was made for laboratory studies as well as diagnostic studies.  Laboratory studies did not reveal any significant findings.  A computed tomography (CT) scan of the abdomen and pelvis revealed thickening of the proximal to mid descending colon with surrounding phlegmonous and inflammatory changes consistent with diverticulitis.  There was a hypodense lesion within the pancreatic tail and further evaluation was recommended with a nonemergent magnetic resonance imaging (MRI).  It was recommended that the patient initiate Levaquin every 8 hours.  The recommendation was made to continue treatment and admit the patient.  The documentation indicated she underwent an infectious disease consult where it was recommended she continue with additional antibiotics that included IV (intravenous) meropenem.  The recommendation was also made to insert a peripherally inserted central catheter (PICC) line.  She continued treatment and the following day it was noted she was refusing a PICC line.  She stated she also did not want IV fluid as it makes her anxious.  The recommendation was made to continue with IV antibiotic treatment.  She was seen where she denied abdominal pain.  She was walking around her room without discomfort.  She was tolerating her diet.  It was recommended to continue with IV antibiotics.  She was wanting to go home.  She refused outpatient antibiotic therapy.  the documentation detailed she did leave against medical advice.

According to referenced literature an inpatient admission may be appropriate when there is documentation detailing persistent hemodynamic instability, peritoneal signs, persistent gross bleeding per rectum, significant abnormality on imaging, or evidence of deficits necessitating inpatient services.  The submitted documentation does not detail any of the above.  While it is noted the patient was recommended to undergo evaluation at the emergency department, there is no indication of a need for inpatient services.  The documentation did detail the patient was allergic to multiple medications; however, there is no significant abnormalities warranting the requested admission.  She could have been treated at a lower level and therefore, the requested full hospital admission was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.