Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological/Gynecological/Abdominal Bleeding due to Leiomyoma of Uterus.
Treatment: Inpatient Admission.
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

This patient is under consideration for admission to acute inpatient level of care for the indication of abnormal bleeding due to leiomyoma of the uterus. The patient is a female who was taken to the operating room for a diagnosis of abnormal uterine bleeding due to leiomyomata of the uterus. The patient underwent a supracervical hysterectomy by laparotomy with cystoscopy, myomectomy and exploratory laparotomy. The surgery was uncomplicated with an estimated blood loss of 500 milliliters (mL). Following surgery, the patient was documented to have pain well controlled with minimal to no vaginal bleeding. She was not ambulatory but was taking water. She had no nausea or vomiting. There was no flatus or bowel movement. She denied headache, dizziness, chest pain, shortness of breath or leg pain. There was 350 cubic centimeters (cc) of urine in the Foley. Vitals remained stable. The patient was planned to remain in hospital until all goals were met. The postoperative course was uncomplicated, and the patient had a stable hemoglobin and hematocrit. She was continued on Methadone and was discharged to home with follow-up in 2 weeks in the outpatient setting.
At issue is the medical necessity for the inpatient admission.

I uphold, in whole, the health plan's determination of medical necessity in this case.

In this case, American College of Obstetricians and Gynecologists (ACOG) recommends implementation of Enhanced Recovery After Surgery (ERAS) pathways. The basic principles of ERAS include attention to the following: preoperative counseling and nutritional strategies, including avoidance of prolonged perioperative fasting; perioperative considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis. Benefits of ERAS pathways include shorter length of stay, decreased postoperative pain and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction. Implementation of ERAS protocols has not been shown to increase readmission, mortality, or reoperation rates. In this case, the minimal invasive approach to surgery and normal recovery would be anticipated to result in observation level of care or discharge to home after surgery. In this case, the patient met the ability to have pain controlled with oral medications, tolerate regular diet, and ambulate. She had no limitations to understanding post operative instructions. Thus, she was eligible for observation level of care and discharge to home. Based upon a review of the medical records and the procedures and course of care, there would be no medical necessity for an acute inpatient level of care for a postoperative stay after a supracervical hysterectomy and cystoscopy.