Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis. 
Treatment: Inpatient Admission. 

The insurer denied: Inpatient Admission. 
The denial is upheld. 

The patient is a female with medical history of ulcerative colitis. She presented to the emergency department with abdominal pain and right lower quadrant tenderness for a day, as well as nausea. She was on Humira and mesalamine. 

Vital signs were unremarkable. Physical examination was notable for right lower quadrant tenderness. Labs showed unremarkable complete blood count, low sodium of 135 millimoles per liter (mmol/L), elevated bilirubin of 3.4 milligrams per deciliter (mg/dL), and elevated C-reactive protein of 15.5 mg/dL. Computed tomography scan of the abdomen and pelvis showed acute inflammatory process involving the ascending colon, most likely acute diverticulitis; the differential diagnosis included acute epiploic appendagitis and omental infarct, but there was no evidence of acute appendicitis. Ultrasound of the right upper quadrant showed no sonographic evidence of gallbladder pathology, and mildly prominent periportal echoes liver which can be associated with hepatitis. She was treated with intravenous fluids, ceftriaxone, metronidazole, and morphine. She was made nothing by mouth (NPO) status. Gastroenterology consultation concluded that she had acute diverticulitis, and recommended continuing intravenous fluids, NPO and advance diet as tolerated, continue ceftriaxone and metronidazole, continue mesalamine, and follow-up as outpatient, with no acute intervention required as inpatient. The next day she still had severe pain and tenderness in the right lower quadrant, with difficulty sleeping, and had started a full liquid diet. Labs showed unremarkable complete blood count and elevated bilirubin of 2.6 mg/dL. The next day she reported five watery bowel movements. Labs showed unremarkable complete blood count, and low potassium of 3.3 mmol/L. The next day, her pain was much improved, and she tolerated a dysphagia diet. Labs showed unremarkable comprehensive metabolic panel. The next day, she was tolerating regular food, without fever or loose bowel movements. Labs showed unremarkable basic metabolic panel. She was discharged on ciprofloxacin and metronidazole for three days, with a plan for Primary Care and Gastroenterology follow-up. At issue is the medical necessity for an inpatient admission. 

The health plan's determination is upheld. 

The inpatient admission is not supported as medically necessary, and the care provided could have been provided at a lower level of care status for the duration of the stay. In patients with uncomplicated diverticulitis (without complications such as abscess or perforation), outpatient management or observation is the standard of care [1]. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated [2]. 

A lower level of care can be appropriate when there are significant symptoms, as in this case [5-8]. However, there was no protracted fever or hypotension. The patient had gradual resolution of symptoms with conservative management including antibiotic therapy. Additionally, imaging did not show complications of her Ulcerative Colitis such as toxic megacolon, and the patient did not have protracted hypotension, peritonitis, bowel obstruction, sepsis, abscess, significant gastrointestinal bleeding or anemia, or perforation to support the inpatient level of care for the treatment of Ulcerative Colitis [9,10].