Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The insurer has denied coverage for inpatient admission. In their Final Adverse Determination letter, they write that the patient asked for an inpatient admission because the patient came to the emergency room and was admitted to the hospital for work up of colitis (an inflammation of the intestines). To approve this service, certain criteria must be met. These criteria were not met because a review of the records shows that the patient could have been managed in a lower level of care (observation), where the patient could be treated for symptoms and observed for response to treatment.

In an appeal letter, the hospital writes that the patient presented to the (Emergency Department) ED with complaints of a 1-month history of worsening left lower quadrant abdominal pain and hematuria with frequency and recent treatment with antibiotics for an "abdominal infection". The patient was found to be hypertensive with blood pressure 147/84 and physical examination revealing abdominal tenderness in the left lower quadrant with abnormal labs and computerized tomography (CT) scan of the abdomen/pelvis revealing "Annular mural thickening of the sigmoid colon with adjacent fat stranding." The patient was subsequently admitted to inpatient level of care for continued diagnostics and management with a treatment plan for (intravenous) IV fluids, IV antibiotics, pain management, lab monitoring, urology and infectious disease consultations. 

The patient has a history of immunocompromised status and presented with ongoing abdominal pain and hematuria. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. An abdominal computed tomography (CT) scan revealed thickening of the wall of the sigmoid colon with adjacent fat stranding. This finding was also present on a previous exam. There was also a possibility of a fistula to the bladder and cystitis. It was determined that the patient should be admitted for a colonoscopy. Antibiotics were given as well as immunosuppressive medications. No acute urology intervention was advised except to obtain a CT scan cystogram. A foley catheter was advised but refused. The colonoscopy showed an anal fissure and sigmoid inflammation. No complications were reported. 

Medical necessity was determined using Milliman Care Guidelines (MCG) guideline M-170 for Gastroenteritis. Clinical indications for admission include having a severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had colonic inflammation and required a colonoscopy and a urology evaluation for hematuria. The patient was stable to have had this done on an outpatient basis. The colitis could have been treated with a course of oral antibiotics as an outpatient. No acute urological evaluations were needed, and an outpatient urology workup could have been done. There was no evidence of sepsis or a severe systemic infection. The patient did not meet MCG criteria for admission for gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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 inpatient admission is not substantiated.