Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Enlarged fibroid uterus
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

This patient is an adult female who presented for a hysterectomy secondary to enlarged fibroid uterus. She had an uncomplicated total abdominal hysterectomy with bilateral salpingectomy. Estimated blood loss was 150 cubic centimeters. Findings revealed a 14-week bulky uterus and a normal adnexa. She was transitioned to the post-anesthesia recovery area. She had intravenous fluids running and a Foley catheter in place. She required pain medication. She had an episode of dizziness, low blood pressure, and vomiting. She was given an intravenous 
fluid bolus and Zofran. On post-operative day 1, the patient's Foley catheter was removed, and her diet advanced. She 
was able to ambulate and void. She was not passing flatus. She was requiring Tylenol, ibuprofen, and oxycodone for pain management. On post-operative day 2, the patient was passing flatus, tolerating diet, ambulating, and voiding. Her pain was controlled. She was discharged home. The inpatient hospital stay was denied coverage by the health plan. This denial is being appealed.

The Inpatient admission was medically necessary.

In a review of the current literature (1), the average length of hospital stay after abdominal hysterectomy in the United States is three days. Routine postoperative care includes monitoring of a patient's hemodynamic and fluid status, pain control, and reintroducing normal diet and activity. Postoperative pain is managed initially with parenteral administration of analgesics. 
Patient-controlled anesthesia is an option. This is transitioned to the oral route when a patient can tolerate oral intake, usually on the first postoperative day. The bladder catheter can be removed during the first 24 hours postoperatively. A systematic review of randomized trials was conducted regarding use of urinary catheterization after urogenital surgery in adults. Fewer urinary tract infections resulted when a catheter was removed after one versus three days. Also, decreased risk of recatheterization was associated with use of a postoperative catheter versus no catheter, as well as with a suprapubic catheter versus a urethral catheter. However, placement of a suprapubic catheter involves an additional incision. Postoperative colonic stasis after major abdominal surgery lasts approximately three days but does not typically require nasogastric decompression or preclude early feeding. Early feeding of a regular diet can stimulate the bowel and decrease the length of hospitalization, although emesis is common. Preventive measures are appropriate for patients at high risk of postoperative pulmonary complications. All patients are also encouraged to ambulate as soon as is feasible. Discharge criteria following surgery vary depending on the surgical procedure performed. In general, the following are the standard recommendations that the patient must be meeting prior to discharge: 1) adequate pain control; 2) stable vital signs; 3) return of bladder and bowel function; and 4) adequate oral intake. In review of the information provided and the literature, the anticipation was the need for at least two to three overnights in the hospital secondary to an open abdominal incision based on the average length of stay after open surgery. The patient required nursing care for monitoring of vitals, bladder and bowel function, and assistance with ambulation. The patient did not reach the discharge criteria until she was appropriately discharged. The literature does support that open hysterectomies are inpatient procedures. Therefore, the inpatient hospital stay was medically necessary, as it was the standard of care.