Diagnosis: abdominal pain/diarrhea
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld.

The patient is a female with medical history of human immunodeficiency virus on highly active antiretroviral therapy, asthma, hyperlipidemia, opioid use disorder on methadone, and breast cancer status postlumpectomy and radiation therapy. She presented to the emergency department with watery diarrhea for four days, vomiting, and abdominal pain. Vital signs were notable for unremarkable blood pressure of 104/74, pulse of 91/minute, and temperature of 36.9 °C (Celsius). Physical examination was notable for dry mucous membranes, and tenderness to palpation along the lower abdomen without rebound or guarding.

Inpatient Hospital Admission was not medically necessary for this patient.
The patient had a finding of Clostridioides difficile infection with colitis on imaging; however, there was no sustained hypotension, persistent severe volume depletion or sepsis, toxic megacolon, or other reasons for the inpatient level of care such as perforation or abscess. Although uncomplicated Clostridioides difficile infection was present, the patient did not have persistent gastrointestinal bleeding, peritonitis, or other complications warranting inpatient level of care. She was appropriately started on treatment for Clostridioides difficile infection with oral vancomycin, and subsequent symptomatic improvement. The standard of care for the evaluation of Norovirus was appropriately performed, including intravenous fluids and supportive care. Although she had human immunodeficiency virus, her disease was well-controlled on therapy, and there were no complicating factors which would support the inpatient level of care. The measures which were undertaken, including observation, labs, antibiotic administration, Infectious Disease consultation, and gradual advancement of diet, could have been performed at a lower level of care.