Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower abdominal pain, nausea, vomiting
Treatment: Inpatient admission
The health plan denied the inpatient admission. 
The health plan's determination is upheld.

This patient is under consideration of medical necessity for admission to acute inpatient level of care. The patient is a female who presented to the emergency department with complaints of abdominal pain associated with fever, nausea, vomiting and decreased appetite. She denied taking medication for pain and reported no sexual activity or prior history of sexually transmitted infection. The patient had no other complaints. Review of systems was otherwise negative. There was no significant medical or surgical history. The patient was noted to have a temperature of 99 F (Fahrenheit) and a heart rate of 99 beats per minute (bpm). Her blood pressure was normal at 133/56 millimeters of mercury (mmHg). The exam was noted for diffuse lower abdominal pain. There was no costovertebral angle (CVA) tenderness. There was no rebound or guarding. Bowel sounds were normal in all 4 quadrants. Lipase was normal. A complete metabolic panel was normal. The white blood cell count (WBC) was 14.7 with a hemoglobin of 8.4 and hematocrit of 27.6%. The patient underwent an ultrasound that noted the uterus to be 12.6 x 6.9 x 8.0 centimeters (cm). The bilateral tubes were noted to have complex fluid present supporting pyosalpinx. The patient was started on intravenous (IV) fluids and was planned for a computed tomography (CT) of the abdomen and pelvis. Rocephin and Doxycycline were started for antimicrobial coverage. The patient was admitted to the gynecology service for ongoing care. They documented that a urine gonorrhea and chlamydia tests were sent, and a transvaginal ultrasound had noted a complex fluid around the bilateral fallopian tubes suggestive of hydrosalpinx. There was no abscess appreciated. The patient was started on intravenous (IV) Doxycycline and Rocephin with Tylenol in the emergency department and was noted have a fever of 102.4 Fahrenheit at 21:05 PM. The patient had no past medical or surgical history. Cigarette smoking was absent. The patient's maximum temperature was 102.4 F. Her heart rate was 92 bpm, and her blood pressure was 109/58 mmHg. Examination was notable for no purulent discharge from the cervical os on pelvic exam. There is no cervical motion tenderness, and the uterus and bilateral ovaries were normal.

I uphold, in whole, the health plan's determination of medical necessity in this case.

Based upon a review of the medical records in this case in concert with the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition - Pelvic Inflammatory Disease (Acute) guideline, there would have been no medical necessity for admission to acute inpatient level of care in this case of pelvic inflammatory disease. In this case, the patient presented with abdominal pain and ultrasound and computed tomography (CT) scan imaging supporting pyosalpinx consistent with pelvic inflammatory disease (PID). There was no abscess noted on CT or ultrasound. The patient had stable vitals and pain was controlled with oral medications. The patient was appropriately treated with Doxycycline, Ceftriaxone and Flagyl. There was no surgical abdomen. Blood cultures and urine were negative. There was no sepsis or bacteremia.