Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult who has a history of cerebrovascular accident (CVA), anemia, gout, hyperlipidemia, and chronic kidney disease (CKD). The patient had abdominal pain and presented to the Emergency Department (ED). He was diagnosed with diverticulitis and given intravenous (IV) fluids and IV antibiotics. He was discharged after a period of hemodynamic stability.  

Despite the patient's presentation, the care as provided, could have been rendered in its entirety at a lower level of care. The patient had acute diverticulitis; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.

"Treatment is typically aimed at reducing intestinal spasms, which is potentially achievable by increasing fiber and fluids in the diet. Greater intestinal bulk reduces the number of spasms, and as a result, decreases intestinal pressures. Studies found no positive or negative association between diverticular disease and consumption of nuts, grains, potassium, carotene, vitamin C, and magnesium. Data related to the association between diverticular disease and alcohol and red meat consumption is controversial. Most bleeding associated with diverticulosis is self-limiting and does not require intervention. In some cases, however, endoscopic, radiologic, or surgical intervention may be required to stop persistent bleeding ((e.g., injection, coagulation (cautery, argon plasma coagulator), or mechanical devices (clips, bands, loops)). If a source cannot be determined in the case of recurrent bleeding, surgery may be considered to remove portions of the affected intestine (e.g., colectomy). Similarly, in the case of a giant diverticulum, with an increased risk of infection and rupture, surgery is more likely to be considered." (Nallapeta et al., 2022)

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021).

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 the inpatient stay is not substantiated.