Diagnosis: Bloody diarrhea.
Treatment: Abdomen and Pelvis CT Scan.
The insurer denied the Abdomen and Pelvis CT Scan.
The denial is upheld.

The patient is a male with HIV (human immunodeficiency virus) and diabetes, with bloody diarrhea and urgency. His provider ordered CT (computed tomography) scan of the abdomen and pelvis to further evaluate.

No, the requested Abdomen and Pelvis CT (computed tomography) Scan is not medically necessary.
The patient has new onset bloody diarrhea.

The standard of care in the evaluation of bloody diarrhea involves stool cultures, and if negative, flexible sigmoidoscopy. There is no medical literature to support CT (computed tomography) abdomen and pelvis as initial diagnostic testing in a patient with bloody diarrhea. Therefore, the requested CT (computed tomography) abdomen and pelvis is not clinically appropriate, accepted standard of care or medically necessary in this patient.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
A CT (computed tomography) scan of the abdomen is not clinically appropriate or medically necessary in the evaluation of bloody diarrhea in a patient suspected of having acute colitis. Therefore, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.