Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic/abdominal pain, nausea, vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female with a history of pelvic inflammatory disease, syphilis and chlamydia. She presented to the ED (emergency department) with two days of worsening pelvic/abdominal pain, nausea, vomiting.

The patient underwent evaluation with blood work revealing elevated white blood cell count, abnormal urinalysis. Bedside ultrasound revealed large bilateral adnexal masses. CT (computed tomography) scan revealed bilateral ovarian masses, left measuring 7.6 x 4.55 cm (centimeters) and right measuring 10 x 8 cm (centimeters), both loculated, and complex. She was diagnosed with pelvic inflammatory disease with bilateral tubo-ovarian abscesses.

The patient was given and IV (intravenous), fluids, toradol for pain, IV (intravenous) anitbiotics. She had a surgical consult. She was scheduled to have a repeat pelvic ultrasound and IR (interventional radiology) drainage of the abscesses, but she left against medical advice.

Yes, the Inpatient admission was medically necessary.
The female genital tract may be affected by ascending infection, either from sexually transmitted infections or vaginal flora. Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract, involving any or all of the uterus, fallopian tubes, and ovaries; this is often accompanied by involvement of the neighboring pelvic organs. It results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess (TOA).

PID (pelvic inflammatory disease) may be complicated by a TOA (tubo-ovarian abscess), which is an inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs (eg, bowel, bladder); TOA (tubo-ovarian abscess) may also occur without preceding PID (pelvic inflammatory disease). These abscesses are found most commonly in reproductive-age patients and typically result from upper genital tract infection. TOA (tubo-ovarian abscess) typically occurs as a complication of PID (pelvic inflammatory disease).

TOA (tubo-ovarian abscess) is a serious and potentially life-threatening condition. Aggressive medical and/or surgical therapy is required, and rupture of an abscess may result in sepsis. For patients with ruptured abscesses, current mortality rates have not been reported, but data suggests the rate may be as high as 1.7 to 3.7 percent. The mortality rate approaches zero for abscesses that are not ruptured.

Treatment modalities for TOA (tubo-ovarian abscess) include antibiotic therapy, minimally invasive drainage procedures, invasive surgery, or a combination of these interventions. The large majority of small abscesses (< [less than] 7 cm [centimeters] in diameter) resolves with antibiotic therapy alone.

The duration of antibiotic therapy required for treatment of a TOA (tubo-ovarian abscess) is not well established. The duration depends upon several factors:

When antibiotics alone are the chosen therapy, a minimum of 14 days is common practice. This is consistent with the CDC (Centers for Disease Control and Prevention) guidelines on the treatment for PID (pelvic inflammatory disease). When imaging-guided drainage procedures and/or extirpative surgery are used in combination with antimicrobial therapy, there are no data available to formally guide length of therapy, however 10 to 14 days of total antibiotic therapy is usually effective. The overall clinical scenario of each individual patient must also be taken into consideration in these decisions.

Most experts recommend continuation of antibiotic therapy until the abscess has resolved on follow-up imaging studies. This can sometimes require four to six weeks of total antibiotic therapy. In cases in which the patient is improving on antibiotics alone, but the abscess has not completely resolved, longer courses of outpatient antibiotics may be given. Cases that do not resolve with routine therapy are best managed in collaboration with an expert in infectious diseases.

Finishing the course of therapy with oral antibiotics as an outpatient is reasonable in select patients. When patients have demonstrated the criteria below, one can consider completion of the treatment in the outpatient setting. Candidates for outpatient therapy should meet all of the following criteria:

Demonstrate clear clinical improvement, Afebrile for at least 24 to 48 hours, white blood cell counts that have normalized, improving abdominal symptoms with significantly less abdominal tenderness, etc; Able to tolerate oral medications; Able to comply with follow-up communication and appointments.

In review of the medical record, the patient presented with bilateral tubo-ovarian abscess measuring > [less than] 7 cm (centimeters) with pain and an elevated white blood cell count. The literature recommends inpatient setting given the risk of mortality associated with ruptured TOAs (tubo-ovarian abscesses). IV (intravenous) antibiotics and IR (interventional radiology)/surgical intervention were necessary for this patient. Therefore the acute inpatient stay was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The literature supports acute inpatient care for this clinical setting.  Therefore this denial does not follow the recommendations in the literature.