Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Inpatient Stay.
The insurer denied: Inpatient stay.
The denial is: Upheld.

The patient is a female admitted for planned laparoscopic assisted robotic myomectomy. The patient had no significant past medical history other than anemia. She had a prior surgical history total thyroidectomy and laparoscopic myomectomy with lipoma removal from the back. She also had a prior history of cesarean delivery. The patient had a diagnosis of iron deficiency anemia but had no history of coagulation disorder. The patient was noted have a body mass index of 26.9 kilogram per meter squared (kg/m2).

The patient was taken to the operating room for robotic-assisted laparoscopic myomectomy. The patient had a pre-and postoperative diagnosis of uterine fibroids. She had an estimated blood loss of 600 milliliters (mL) during the procedure. The uterus was noted to be 16 centimeters (cm) in size and irregular in contour. This was not mobile and anteverted in position. There were multiple subserosal and pedunculated fibroids with the largest 8 cm in size. A total of 18 fibroids were noted and removed. One fibroid was in the broad ligament on the left side and 3 cm in size. Omental adhesions to the uterine fibroid and anterior abdominal wall were noted and bilateral adnexa appeared normal. The patient underwent an uncomplicated robotic procedure, and all uterine incisions were closed in one layer using suture. The patient tolerated the procedure well and was noted to have no complications of anesthesia. The total duration of surgery was around 6 hours and 13 minutes.
Following surgery, the patient had stable vital signs and pain was well-controlled. She was voiding without difficulty and had no flatus but was noted to be burping. Patient reported feeling stronger and denied fever, chills, shortness of breath, chest pain, nausea or vomiting, or Tenderness. The patient was alert and oriented. Her abdomen was soft, nontender with bowel sounds and no guarding or rebound. She had incision sites that were well-healing. Her hemoglobin and hematocrit were stable. The patient's pain was improved with Toradol, and she was ambulating and voiding. Her vital signs and physical exam were normal, and an exam was negative. Her hemoglobin was 8.1 with hematocrit of 26.9%. This was stable from prior evaluation. The patient was planned for a single dose of Venofer intravenous (IV) iron prior to discharge. The patient was planned to discharge to home with outpatient follow-up in the ambulatory setting. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient who was admitted for a planned uterine myomectomy for uterine fibroids. The Milliman Care Guidelines (MCG) Guideline entitled "Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy" were reviewed in concert with the medical records in this case. The surgical procedure was noted to be a uterine myomectomy by robotic laparoscopy under general anesthesia. The surgery was uncomplicated, and the patient had no anesthesia complications. The surgical time for completion of surgery was approximately 6 hours. Thus, the surgery was completed in usual time for a robotic surgery. There was no excessive blood loss with an estimated blood loss of 600 mL and the postoperative hemoglobin was stable. There was no damage to bowel, bladder, or other intra-abdominal structures. The determination of the length of the necessary stay is based upon the optimal recovery course. The patient was noted to meet all aspects of care required for discharge on the date of admission based upon the documentation reviewed. Thus, in conclusion this patient was found to have no medical necessity for inpatient stay.