Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Diarrhea
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient had abdominal pain and watery diarrhea. She had a 40 pound weight loss over the prior two months. A computed tomography (CT) scan of the abdomen/pelvis showed sigmoid colitis, focal ileus. The patient was given fluids, antibiotics, and admitted to acute care. On the next day, she signed out against medical advice.
The was described as hemodynamically stable with mild tenderness on the right side of the abdomen. There was no evidence of dehydration. The blood pressure (BP) was 167/78, oxygenation 99% on room air, with no fever, lactic acid normal, lipase normal, white blood cell count (WBC) and hemoglobin normal, bilirubin normal, and liver tests normal. She was described as in no apparent distress. A computed tomography (CT) scan of the abdomen/pelvis showed bowel wall thickening in the sigmoid suspicious for colitis. She was given antibiotics, fluids, and placed on a clear liquid diet. By the next day, she did not want to stay in the hospital because she had urgent affairs to take care of at home and she signed out against medical advice. The initial abdominal exam showed tenderness in the right side of the abdomen but no peritoneal signs no guarding or rebound. By the next day, the vital signs remain stable, tolerating the liquid diet, no vomiting, refusing further medical treatment and she signed out against medical advice.
At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary. Once the initial evaluation showed no fever, no hemodynamic instability, no bleeding, no leukocytosis, and no acute abnormality that required acute care on computed tomography (CT) scan, the patient was medically stable for a lower level of care. The CT scan showed some bowel wall thickening in the sigmoid suspicious for colitis. However there was no obstruction, no abscess, no phlegmon, no diverticulitis, no appendicitis, no bleeding, no dehydration, no electrolyte disturbance, no renal failure. A patient with a mild sigmoid colitis could be treated at a lower level of care with fluids, antibiotics and did not require acute care.
Nally described: "Routine use of inpatient, intravenous antibiotics may not be required and outpatient management is possible for certain patients. Universal colonoscopy examination after uncomplicated acute diverticulitis is controversial but is mandatory after complicated episodes. Recent, high-profile, clinical trials suggest that less aggressive surgical management of both acute and chronic presentations may be feasible in some cases. Conclusions: Diverticulitis is a common yet challenging topic that demands clinicians to provide an individualised yet evidence-based approach." Once this patient had no diverticulitis she was stable for a lower level of care (LOC) and did not require acute care.
van Dijk described: "An initial 94% success rate of non-operative treatment in left-sided colonic diverticulitis patients with pericolic extraluminal air seems to justify a conservative approach including antibiotic agents." Once this patient had no diverticulitis she was stable for a lower LOC and did not require acute care.