Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with abdominal pain. She had a history of previous episodes of diverticulitis. She was afebrile and the vital signs were stable. Lower abdominal tenderness was present without rebound or guarding. A computerized axial tomography (CAT) scan showed acute uncomplicated diverticulitis. There was also a question of appendicitis, but no surgical interventions were advised. She was started on intravenous (IV) antibiotics and then switched to oral antibiotics.

Clinical indications for admission for acute diverticulitis (Milliman Care Guidelines M-150) include hemodynamic instability, peritoneal signs, persistent gross bleeding, or significant complications seen on imaging. This imaging abnormality can be a fistula, obstruction, perforation, or abscess. The patient did not have these conditions. She also did not have bacteremia, severe vomiting, an inability to maintain oral hydration after observation care, or need an inpatient surgical intervention.

This patient had an uncomplicated diverticulitis. IV hydration and pain medications could have been given in the emergency room. Afterwards, she could have been discharged on a course of oral antibiotics. She did not meet Milliman Care Guidelines (MCG) criteria for admission for acute diverticulitis. She could have been managed with observation status.

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

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