Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hysterectomy
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with Factor V Leiden gene mutation.  She underwent an open hysterectomy, lysis of adhesions, bilateral salpingectomy, and umbilical hernia repair.  This was uncomplicated.  On post-operative day #1 (number one), the patient was not passing flatus, she was only tolerating liquids and had not been out of bed.  She was anemic with a hemoglobin of 10.7.  Her Foley catheter was removed, her diet was advanced, and she was helped with ambulation.  She was also started on Lovenox to prevent a blood clot.  On post-operative day #2 (number two), the patient had low blood pressure.  She was still not passing flatus, tolerating liquids, and ambulating.  The pain was managed with oxycodone.  Decision was to keep her in the hospital until return of bowel function.  Later that day, the patient had upper abdominal pain and had some vomiting.  She then had some anti-emetics and felt better.  On post op day #3 (number three), the patient was feeling better.  Her pain was well controlled, she was ambulating, voiding, tolerating diet, and had had return of bowel function.  She was discharged home with outpatient follow up. This inpatient hospital stay is being denied.  This is being appealed.

The proposed inpatient hospital admission was medically necessary.
In a review of the current literature summarized by Stovall and Mann, 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. 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
4)  adequate oral intake.

In review of the medical record the patient underwent an open abdominal hysterectomy.  She did not meet the discharge criteria until day #3 (number three) post surgery.  Because the hospital stay crossed two midnights and the literature supports a three day stay, the inpatient hospitalization was necessary.