Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The proposed inpatient treatment for this patient's diverticulitis was not medically necessary. 

The patient is a male. He presented with two days of abdominal pain. The pain was crampy, intermittent, and associated with bloating and fullness, and with two to three episodes of non-bloody loose stools. He had a past history of perforated diverticulitis treated conservatively. 

The patient was noted to be hemodynamically stable, with heart rates of 93 and 101 initially. His abdominal exam was documented as soft, distended with mild tenderness in lower abdomen and no masses. Electrolytes, UA (urinalysis), and LFTs (liver function tests) were normal. WBC (white blood count) was 16.8K with a slight left shift (N=85.4). CT showed colon thickening and multiple bubbles of air about the colon and mesenteric fat, consistent with perforation. The patient was admitted for IV antibiotics and bowel rest. 

On the first hospital day (HD), the patient was without fever, nausea, vomiting or chills. He was up, ambulating. His pain score was 0, and heart rate was 104. Tenderness was noted in the LLQ (lower left quadrant). The WBC was down to 10.8K, with an improving left shift. His diet was advanced, and he was discharged on HD #2 with oral antibiotics. 

The patient had uncomplicated diverticulitis that was amenable to outpatient treatment. 

Acute diverticulitis is suspected in patients with lower abdominal pain (typically in the left lower quadrant), abdominal tenderness on physical examination, and leukocytosis on laboratory testing. To exclude alternative conditions (e.g., colon cancer, irritable bowel syndrome), the diagnosis is usually confirmed by an abdominopelvic computed tomography (CT) scan, which also distinguishes complicated from uncomplicated disease.

In the absence of complications (e.g., frank perforation, obstruction, fistula, abscess), acute uncomplicated diverticulitis can be treated non-operatively in most patients (70 to 100 percent), regardless of the treatment setting (out- versus inpatient). In a randomized trial of 132 patients who received a first dose of intravenous antibiotics in the emergency department, subsequent out- and inpatient treatment resulted in similar failure rates and quality of life.

Acute complicated diverticulitis requires treatment of both colonic inflammation (diverticulitis) and the specific complication (e.g., frank perforation, obstruction, fistula, abscess), which typically requires hospitalization and/or surgery.

Based upon findings from the history, physical exam, and CT scan, patients are triaged to receive either inpatient or outpatient treatment.

Criteria for inpatient treatment - Patients with acute diverticulitis should receive inpatient treatment if: 1) CT shows complicated diverticulitis defined by the presence of frank perforation (e.g., free air under the diaphragm with or without extravasation of contrast or fluid), abscess, obstruction, or fistulization. 2) CT shows uncomplicated diverticulitis but the patient has one or more of the following characteristics: 1) Sepsis. 2)Microperforation (e.g., a few air bubbles just outside of colon, or confined to the pelvis) or phlegmon. 3) Immunosuppression (e.g., poorly controlled diabetes mellitus, chronic high-dose corticosteroid use, use of other immunosuppressive agents, advanced HIV infection, B or T cell leukocyte deficiency). 4) High fever (>102.5F/39C). 5) Significant leukocytosis. 6) Severe abdominal pain or diffuse peritonitis. 7) Age >70 years. 8) Significant comorbidities. 9) Intolerance of oral intake. 10) Noncompliance/unreliability for return visits/lack of support system. 11) Failed outpatient treatment.

There were neither subjective nor objective criteria for inpatient admission for this patient with uncomplicated diverticulitis. The patient could have been treated at a lower level of care.