Diagnosis: Pelvic inflammatory disease.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She presented with a chief complaint of pelvic pain.

The patient's vital signs were stable. Physical examination was normal except for cervical motion tenderness. The patient was diagnosed previously with endometriosis.

The patient was admitted with the diagnosis of PID (pelvic inflammatory disease) complicated by a history of endometriosis and suspected pelvic myofascial pain syndrome. She received IV (intravenous) antibiotics for 24 hours and was discharged on progestin to treat her endometriosis, Gabapentin, and Tylenol for pain, and Sertraline for depression anxiety. She was discharged.

Yes, the Inpatient admission was medically necessary.

The presumptive clinical diagnosis of PID is made in sexually active young women, especially women at high risk for sexually transmitted infections (STIs), who present with pelvic or lower abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam.

The sensitivity of this clinical diagnosis is only 65 to 90 percent but because of the potential for serious reproductive sequelae if PID treatment is delayed or not given, this presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID. Even patients with minimal or subtle findings should be treated since the potential consequences of withholding therapy are great.

So even though this patient did not have the typical PID presentation (no fever, no abnormal cervical or vaginal mucopurulent discharge or cervical friability), treating her for possible PID was warranted.

There has been a persistent trend toward outpatient treatment of PID with only 15 percent of women now being hospitalized. Clinical trial data support such an approach in patients with mild or moderate PID.

Recommended indications for hospitalization and parenteral antibiotics include the following:

1) Pregnancy 2) Lack of response or tolerance to oral medications 3) Nonadherence to therapy 4) Inability to take oral medications due to nausea and vomiting 5) Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain) 6) Complicated PID with pelvic abscess (including tubo-ovarian abscess) 7) Possible need for surgical intervention or diagnostic exploration for alternative etiology (e.g., appendicitis)

This patient had severe pain. While PID was suspected, she also had a history of endometriosis complicating her presentation. In addition, she had elevated white count, nausea and vomiting and has a history of poor adherence to antibiotics. The pain was severe, necessitating IV morphine.

Based on the above, the inpatient care from was medically necessary.

The health Plan should allow admission as the admission was medically necessary.