Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Perforated diverticulitis.
Treatment: Interfacility Transfer.
The insurer denied: Interfacility Transfer.
The denial is overturned.

This patient is an adult female who presented to the initial hospital with complaints of abdominal pain. She was diagnosed with perforated diverticulitis and was admitted. She was treated with nothing by mouth status, intravenous fluid and intravenous antibiotics. On Day #4, the patient's abdominal pain worsened, and a repeat computed tomography scan showed the interval development of an abscess in the left lower quadrant, new pelvic ascites, persistent inflammatory changes in the left lower quadrant, and free air in the upper abdomen. The patient was treated with percutaneous drainage of the abscess. The patient's appeal letter states that the resident physicians at the initial hospital communicated to her that she would likely require surgery to remove the involved colon and divert stool with a colostomy. Her letter states that a request for transfer to a specialist at the receiving hospital was requested by her doctors at the initial hospital. Authorization for transfer was obtained from the health plan and the patient was transferred to a colorectal specialist surgeon at the receiving hospital. The drain output appeared feculent. The white blood cell (WBC) count on the day after transfer was 7.6 thousand (K). A repeat computed tomography scan was performed with oral, intravenous and rectal contrast to assess for ongoing enteric leak/fistula. This computed tomography showed interval decrease in size of the left pelvic abscess and no contrast extravasation to suggest a fistulous connection. There was stable moderate pneumoperitoneum. The patient was provided parenteral nutrition as she had been nothing by mouth for seven-days.

The antibiotic regimen was altered. On Day #3 the physical exam revealed tenderness with voluntary guarding in the left lower abdominal quadrant. The previously placed drain was in place with decreased output. The patient responded favorably to the treatment provided. She was started on a liquid diet and was able to be discharged home without need for acute or emergent surgery. She was prescribed oral antibiotics post-discharge. 

Interfacility transfer from the initial hospital to the receiving hospital was medically necessary.

The records in this case indicate that this patient had perforated diverticulitis. Her initial therapy until transfer on Day #6 was reasonable and appropriate. However, this treatment was provided by a general surgeon rather than a colorectal surgical specialist. While general surgeons do routinely provide care and treatment for diverticulitis, in this case the records indicate that there was consideration of need for urgent surgical treatment with colectomy and colostomy at the receiving hospital. There are circumstances when such emergent surgery is necessary. However, upon transfer to the receiving hospital, the patient was evaluated with a rectal contrast enhanced computed tomography scan, provided parenteral nutritional support and the prescribed antibiotics were altered. The patient responded favorably to the treatment provided at the receiving hospital and was able to be discharged without emergent surgical intervention. Interfacility transfer to a colorectal specialist was appropriate and medically necessary in this case as the treatment needs of this patient were either not available or had not been performed at the initial hospital (rectal contrast enhanced computed tomography scan, provision of parenteral nutritional support and alteration of the intravenous antibiotics). Additionally, the treating doctor at the initial hospital was not a colorectal specialist. These circumstances support the medical necessity of interfacility transfer for this patient.