Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is overturned.

The patient is a male with a past medical history significant for hypertension, diabetes mellitus, chronic kidney disease, peripheral neuropathy, and chronic obstructive pulmonary disease (COPD) who presented with complaints of left lower quadrant pain. The patient stated that since the pain started, he was unable to eat due to severe nausea. At the same time, the patient denied vomiting. He initially had diarrhea, which resolved by the time of the presentation. The patient also reported chills.
Evaluation  in the emergency department revealed that the patient had acute diverticulitis. He received intravenous antibiotics.
While seen by the admitting physician, the patient was afebrile. Heart rate was 85 beats per minute, respiratory rate was 18, blood pressure was 159/70, and oxygen saturation was 100% on room air. The abdomen was tender and distended without rebound or guarding. Bowel sounds were present. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 9.5, hemoglobin was 9.2, hematocrit was 29.4, and platelets were 179. Sodium was 142, potassium was 3.8, chloride was 111, bicarbonate was 26, blood urea nitrogen (BUN) was 17, creatinine was 1.52, and glucose was 139.
The patient was admitted to the hospital with a diagnosis of diverticulitis. The patient continued to receive treatment with intravenous antibiotics and intravenous fluids which were initiated in the emergency department. Reportedly, because of continuous severe abdominal pain, the patient received treatment with intravenous Morphine.
The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is overturned.

The inpatient hospital admission was medically necessary. The severity of the patient's condition and the treatment provided in the hospital justified admission at the acute inpatient level of care The medical records included a history and physical exam note as well as progress notes. The review of the medical records demonstrated that during these days the patient still had significant abdominal pain, which was attributed to acute diverticulitis. This patient required administration of intravenous pain medication because of severe abdominal pain related to acute diverticulitis. The patient also required administration of intravenous fluids to prevent dehydration in the setting of persistent abdominal pain that affected normal oral intake. It was clearly indicated that the patient still continued with significant abdominal tenderness, and still required treatment with intravenous antibiotics. In addition, the review of the laboratory results demonstrated deterioration of kidney function over the course of several days necessitating very close monitoring for signs of dehydration and antibiotic toxicity.
It is a common clinical practice that patients with severe abdominal pain that require frequent administration of intravenous pain medications need admission at the acute inpatient level of care. This was also mentioned in the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition criteria for acute diverticulitis. In addition, the patient had a very diminished oral intake, because of persistent abdominal pain that predisposed him to possible dehydration if remained untreated with intravenous fluids.
Taking into consideration all these facts, the admission at the acute inpatient level of care was appropriate.