Diagnosis: Diverticulitis and abscess

Treatment: Inpatient admission, medication, monitoring
The insurer denied the inpatient admission. The denial was reversed.
The patient had been hospitalized at another hospital for perforated diverticulitis with an abscess. She had three prior episodes of diverticulitis. A Computerized Axial Tomography (CAT) scan revealed the perforated diverticulitis and abscess. The patient was started on intravenous (IV) Zosyn. On exam, tenderness was present in the lower abdomen without rebound or guarding. Upon transfer, intravenous (IV) antibiotics were continued. A repeat CAT scan showed acute diverticulitis with increasing adjacent phlegmonous changes. A new air-fluid collection was seen compatible with a fistulizing abscess.
Clinical indications for admission for acute diverticulitis (M-150) include a significant abnormality complicating the diverticulitis. Both a fistula and abscess are listed as significant abnormalities that are indications for admission.
At the time it was thought the patient required surgery and the services were stated as not available at the prior hospital. This patient had diverticulitis which was complicated by an abscess and fistula. Intravenous antibiotics were given. The patient met Milliman Care Guidelines (MCG) criteria for inpatient care even if no surgery was done. MCG guidelines for admission for acute diverticulitis do not require that there is a plan for surgery. The patient can be treated under these guidelines with intravenous (IV) antibiotics.
The carrier's denial of coverage for the inpatient hospital services is reversed. The medical necessity is substantiated.