Diagnosis: Diverticulitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This patient presented to the emergency room (ER) with 2 days of left lower quadrant abdominal pain, nausea, vomiting and diarrhea. On exam, the patient appeared stable. The exam was notable for left lower quadrant tenderness on palpation without guarding or rebound. The laboratory evaluation showed leukocytosis of 17. The patient was treated with intravenous (IV) antibiotics and their diet was kept nothing by mouth (NPO).
A computed tomography (CT) of the abdomen revealed sigmoid diverticulitis with evidence of perforation. A surgery consultant recommended medical management and to advance diet to clear liquids. The patient was doing well without complaints and leukocytosis resolved. The patient was discharged to home with instructions to take 5 days of antibiotics. At issue is the medical necessity of the inpatient hospital stay.

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

The patient had localized diverticulitis without complication. There was no need for surgical or interventional radiology intervention. The patient's exam never suggested peritonitis. The patient's diet was quickly advanced.