Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/ Gastrointestinal - Abdominal/Stomach Pain.
Treatment:  Inpatient Hospital Stay.

The health plan denied the inpatient hospital stay as not medically necessary.  The health plan's determination is upheld.

The patient is a male, who presented to the emergency department (ED) with abdominal pain and left flank pain of several weeks duration. His past medical history included hypertension. He had been recently hospitalized for a reported urinary tract infection. His vital signs showed no fever and a heart rate of 81 beats per minute (bpm). The blood pressure was elevated at 146/86 millimeters of mercury (mmHg). At the time of presentation, the white blood cell (WBC) count was normal at 8.5. His hemoglobin was 11.5.

At the time of physical examination there was no abdominal tenderness. A computed tomography (CT) scan of the abdomen was performed that showed short segment diverticulitis of the mid descending colon without evidence for perforation or other complication. He was started on intravenous (IV) fluid and antibiotics for the diagnosis of diverticulitis. He was admitted to the hospital with the primary diagnosis of acute sigmoid diverticulitis. It was anticipated that he would require days of IV antibiotics.
Surgical consultation was obtained. The patient had normal vital signs. He was continued on IV antibiotics. The patient reported improvement in the abdominal pain complaints. The patient was discharged from the hospital with instructions for outpatient follow up.

At issue is the medical necessity of the inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

The inpatient admission was not medically necessary for this patient.

This patient presented with abdominal/flank pain. His initial evaluation identified a nontender abdomen, a normal WBC count, and an abnormal CT scan consistent with acute diverticulitis without perforation. The examination did not identify peritoneal signs. The patient was appropriately started on IV antibiotics. The patient required IV fluid and IV antibiotics, and follow up exam and lab assessment. The next day the patient reported improvement in the pain complaints. The patient continued to have normal vital signs and progressive clinical improvement. The surgical assessment states that the patient had resolved diverticulitis and was stable for discharge with planned outpatient follow-up.

While diverticulitis carries the potential for clinical deterioration, this patient was clinically stable at the time of presentation and showed prompt clinical improvement with provision of antibiotics. The submitted records reference Milliman Care Guidelines (MCG) Diverticulitis. Per these guidelines admission is indicated for one or more of the following: Hemodynamic instability, peritoneal signs, persistent gross bleeding per rectum, significant abnormality on imaging such as fistula, obstruction, frank or free perforation, drainage procedure, bacteremia, severe pain, monitoring that is severe or persistent, dehydration, inability to maintain oral hydration, parenteral nutrition regimen.
In this case there was no documentation of progressive clinical deterioration related to acute diverticulitis. The patient did not have peritoneal signs of evidence for perforation based on initial CT imaging. He was able to tolerate a liquid diet.

Acute inpatient care was not medically necessary for this patient as the care, and treatment provided could have been rendered with a lower level of care.