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202307-165611

2023

Empire Healthchoice Assurance Inc.

PPO

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Bowel Problem (diverticulitis).
Treatment: Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission. The denial is upheld.

This patient is an adult female who presented to the emergency room with progressively worsening constant, moderate, lower abdominal pain for five days. The patient presented to the emergency room and was discharged on day #3. The patient had gas-like cramping and constipation. The patient reported an inability to eat for five days secondary to the pain. The patient's white blood cell (WBC) count was 14.3. Computed tomography (CT) scan of the abdomen/pelvis showed severe diverticulitis in the left lower quadrant (LLQ) without perforation or abscess. In the emergency room, the patient was treated with intravenous Cipro 400mg (milligrams) x 1 (one time), intravenous Ketorolac 15mg (milligrams) x2 (two times), intravenous Morphine 4mg (milligrams) x1 (one time), intravenous fluids, and nothing by mouth (NPO). On day #2, the patient reported mild left lower quadrant pain. There were no overnight events. A regular diet was started, and the patient was reportedly tolerating her diet well and having regular bowel movements. Additionally, there were no fevers/chills. The request for coverage of the inpatient hospital admission is under review.

The requested health service of an Inpatient Hospital Admission is not considered medically necessary.

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding, nor was there an evaluation requiring the patient to not eat or drink for an extended period (e.g., (for example) more than 24 hours). Additionally, the patient did not have an inability to maintain oral hydration (e.g. (for example), needs intravenous fluid support) that persists after observation care, and she did not have suspected toxic megacolon, nor bacteremia. Furthermore, the patient did not require a procedure that could not have been performed on an ambulatory basis. As such, the requested inpatient admission would not be considered medically necessary.

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