Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis.
Treatment: Inpatient Hospital Stay.

The insurer denied the inpatient hospital stay.  The health plan's determination is upheld.

The patient is a female, who initially presented to the emergency department with concerns for vaginal and rectal pain. Her pertinent history included ulcerative colitis and migraine headaches. The initial vital signs revealed a temperature of 98.4, heart rate (HR) 98, blood pressure (BP) 118/71, respiratory rate (RR) 18 and her peripheral capillary oxygen saturation (SpO2) was 100 percent (%). The initial examination documented the patient as alert without peritoneal signs. The initial laboratory testing revealed a white blood cell count (WBC) of 6.1, hemoglobin 14.2, platelets (Plt) 281, sodium 140, potassium 3.7, blood urea nitrogen (BUN) 12, creatinine 0.69, and her glucose was 84. The urinalysis was relatively unremarkable.

The computed tomography (CT) of the abdomen and pelvis revealed no evidence of bowel obstruction or colitis with a trace amount of air in the region of the vaginal fornix. Obstetrics and gynecology was consulted and documented an impression of pain most likely colorectal in origin. Recommendations were to ingest high fiber food, increase oral hydration, and to complete a course of Fluconazole for a yeast infection. The patient was placed in the hospital thereafter with an impression of rectal and vaginal pain. The treatment plan included Prednisone times 1, supportive care, resumption of home medications, and additional consultations. Gastroenterology was consulted and recommended a flexible sigmoidoscopy to evaluate proctalgia. This was performed without issue or complication. No polyps, masses, lesions, or bleeding sites were identified. Supportive care continued. 

Cohee et al. notes common anorectal conditions include hemorrhoids, perianal pruritus, anal fissures, functional rectal pain, perianal abscess, condyloma, rectal prolapse, and fecal incontinence. Although these are benign conditions, symptoms can be similar to those of cancer, so malignancy should be considered in the differential diagnosis. History and examination, including anoscopy, are usually sufficient for diagnosing these conditions, although additional testing is needed in some situations. The primary treatment for hemorrhoids is fiber supplementation. Patients who do not improve and those with large high-grade hemorrhoids should be referred for surgery. Perianal pruritus should be treated with hygienic measures, barrier emollients, and low-dose topical corticosteroids. Capsaicin cream and Tacrolimus ointment are effective for recalcitrant cases.  

The patient had a history of ulcerative colitis who presented with vaginal and rectal pain. There was no associated fever, bloody diarrhea, or peritoneal signs. A comprehensive evaluation was performed including laboratory testing, CT imaging, and flexible sigmoidoscopy which were relatively unremarkable for an acute pathological process. The treatment plan was largely supportive including increased fiber intake and analgesia. Following an alternate level of care, clinical improvement was achieved. No other issues or complications were documented.

Clinical indications for admission to inpatient care were not met. The patient did not have peritoneal signs, bloody diarrhea, abdominal abscess, fistulizing Crohn's disease, acute severe ulcerative colitis, evaluation requiring the patient to not eat or drink for extended period (more than 24 hours) or hemodynamic instability. The patient did not have severe pain requiring acute inpatient management, identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia), signs of intestinal obstruction, suspected toxic megacolon, bacteremia, severe electrolyte abnormalities requiring inpatient care, inability to maintain oral hydration that persists after observation care treatment, or a surgery needed that cannot be performed on ambulatory basis.[2][3]