Diagnosis: Acute colitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The patient had a history of cardiac disease, diabetes, and celiac disease. The patient presented with abdominal pain and diarrhea. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A Computerized Tomography (CT) scan showed acute colitis. Stool testing was ordered, and pain medications were given. The patient's symptoms improved and the patient was able to tolerate a diet.

Medical necessity was determined using Milliman Care Guidelines (MCG) M-170 for Gastroenteritis. Clinical indications for admission include having a severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had evidence of colitis on the CT scan. The patient could have been treated for the gastroenteritis with intravenous (IV) hydration and pain medications in the Emergency Room (ER) as an outpatient. If antibiotics were felt to be necessary, the patient could have been treated with a course of oral antibiotics as an outpatient. The patient did not meet MCG criteria for admission for Gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient admission from is not substantiated.