Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tubo-ovarian abscess.
Treatment: Inpatient hospital stay.
The insurer denied  Inpatient hospital stay. 
The health plan's determination is overturned.  

The patient is a woman. She presented to the emergency room with complaints of abdominal pain, nausea and vaginal bleeding. 

On admission, the patient was afebrile with normal vital signs except a mild tachycardia. The patient spiked a 102.9 fever with tachycardia while in the ER. A pelvic examination revealed cervical motion tenderness and abdominal exam lower abdominal tenderness. Laboratory testing results included leukocytosis and neutrophilia, mild low hemoglobin and urine with trace leukocyte esterase and WBC (white blood count).

CT scan revealed a right ovarian mass, and a diagnosis of a right tubo-ovarian abscess with pelvic inflammatory disease was made. The patient was admitted to the inpatient service. IV antibiotics, IV fluids and DVT (deep venous thrombosis) prophylaxis were begun.

Patients with adnexal masses may present with symptoms that can refine the differential diagnosis. For example, a woman of reproductive age with acute onset abdominal or pelvic pain may have a hemorrhagic or bleeding ovarian cyst. The potential for pregnancy should be evaluated in all women of reproductive age, because ectopic pregnancy is in the differential diagnosis of an adnexal mass in early pregnancy. Symptoms of unilateral, intermittent, and then acutely worsening pelvic pain may indicate an ovarian torsion. A more indolent, progressive pelvic pain associated with fevers, chills, vomiting, and vaginal discharge may indicate an infectious etiology such as a tubo-ovarian abscess. 

The patient was given a diagnosis of a tubo-ovarian abscess and was admitted as an inpatient for IV antibiotic treatment and observation. The American College of Obstetrics and Gynecology, in its Practice Bulletin, states: "Antibiotic therapy is the first-line treatment for tubo-ovarian abscess. The Centers for Disease Control and Prevention's Sexually Transmitted Disease Treatment Guidelines suggest hospitalization in cases of pelvic inflammatory disease complicated by tubo-ovarian abscess." The CDC (Centers for Disease Control and Prevention), in its guidelines states, "PID treatment regimens must provide empiric, broad spectrum coverage of likely pathogens. Several parenteral and oral antimicrobial regimens have been effective in achieving clinical and microbiologic cure in randomized clinical trials with short-term follow-up. However, only a limited number of investigations have assessed and compared these regimens with regard to elimination of infection in the endometrium and fallopian tubes or determined the incidence of long-term complications (e.g., tubal infertility and ectopic pregnancy) after antimicrobial regimens...Treatment should be initiated as soon as the presumptive diagnosis has been made, because prevention of long-term sequelae is dependent on early administration of appropriate antibiotics. When selecting a treatment regimen, health-care providers should consider availability, cost, and patient acceptance. In women with PID of mild or moderate clinical severity, parenteral and oral regimens appear to have similar efficacy. The decision of whether hospitalization is necessary should be based on provider judgment and whether the woman meets any of the following suggested criteria:...tubo-ovarian abscess..." 

Therefore, given the above, inpatient hospital admission is the standard of care for the treatment of tubo-ovarian abscess.