Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission.  The denial was upheld. 

This patient is a female who was admitted with a chief complaint of right-sided pelvic pain that was intermittent in intensity initially and more constant when she presented to the hospital. The patient was noted to have 9 episodes nonbilious and non-bloody emesis and had not been able to tolerate oral intake. She appeared in acute distress due to pain and there was significant right pelvic tenderness to palpation on exam. A urine human chorionic gonadotropin prove (hCG) was noted to be negative. A bedside ultrasound was concerning for ovarian torsion however the findings were also consistent with a possible ruptured cyst. The obstetrics/gynecology (OB/GYN) service was consulted, and the decision was made to obtain a computed tomography (CT) scan for further delineation.

The patient was noted to have a right-sided ovarian cyst that was known.  The patient's medical history was noted for sickle cell trait. The cervical os was closed, and there was absent cervical motion tenderness but noted right-sided adnexal tenderness. She reported the pain was worse when lying down. The patient underwent a bedside ultrasound which showed the uterus to be 6.76 by (x) 3.44 centimeter (cm). The right and left ovaries were noted to be normal with the right ovary having intermittent blood flow. 

The patient was taken to the operating room where she underwent an examination under anesthesia, exploratory laparotomy, and right salpingo-oophorectomy under general anesthesia. She was noted to have a small uterus with a right ovarian cyst of 3 cm at the time of surgery. The mass was bluish purple, and the ovarian mass was 7 x 4 cm with torsion noted about a pedicle 5 times. There was no normal ovarian tissue that was identified. For this reason, the patient underwent a right-sided salpingectomy. Following surgery, her vital signs remained stable, and her hemoglobin and hematocrit were stable. The cyst was suspected to be a dermoid cyst.

The patient was noted to be reporting flatus and tolerating an oral diet and had voided and ambulated. The patient's incisions were healing. The patient was discharged to home.

At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.

The patient had no nausea or vomiting ongoing and was not noted to be hemodynamically unstable or dehydrated. There was no evidence of bleeding at a significant rate by labs, ultrasound, or clinical status. There was no surgical emergency or acute blood loss.

Based on review of the medical documentation, there was no medical necessity for an acute inpatient admission, as the patient had no evidence of acute bleeding or worsening abdominal exam. The patient was noted to have normal vital signs with a normal hemoglobin and hematocrit that were stable. There was a known cyst, and this was a torsion. Surgery was completed with minimal blood loss (20 cubic centimeters) and without complications. Given the stable vital signs and afebrile status, this patient was not noted to have any source of infection. 

Therefore, the inpatient level of care was not medically necessary.