Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute diverticulitis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld.

According to the clinical documentation provided for review, the patient is a male with the medical diagnosis of left shoulder melanoma and uncomplicated diverticulitis. The patient has been seen and treated with a past medical history (PMH) of left shoulder melanoma and uncomplicated diverticulitis. The patient presented to the emergency department (ED) with worsening left lower quadrant (LLQ) pain which the patient failed outpatient treatment with oral antibiotics. He was originally treated with cipro/flagyl and then switched to augmentin. The patient was afebrile, abdomen was nondistended with normal BS (bowel sounds). He was tender to palpation (TTP) in the LLQ region. The CT (computed tomography) scan showed an area of wall thickening with adjacent fat stranding compatible with acute diverticulitis. There was no ascites or free air. Labs showed WBC (white blood cell count) of 9.5. The patient was admitted for further observation (OBS) on intravenous (IV) antibiotics (ABX) Zosyn. 

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 diverticulitis with no evidence of 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 non-inpatient level. 

"Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review." (Rezapour, et al., 2018).                                                         

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.