Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine Fibroids
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a female who presented for surgical management of uterine fibroids. She had been evaluated for abdominal bloating, abdominal pain, infertility and menorrhagia. The patient had no active complaints at the time of presentation. She denied fever, chills, cough, shortness of breath, chest pain, myalgia, fatigue, sick contacts, pain and had remained nothing by mouth overnight. The patient's past medical history was noted for obesity, chronic hypertension, hypothyroidism, Sjogren syndrome and sleep apnea. The past surgical history was denied. The patient's medications included labetalol 300 milligrams (mg) twice daily and Synthroid 50 micrograms (g) per day. The patient reported no known allergies. Her hemoglobin was 12 with hematocrit of 36 with platelets of 223. The patient had a normal basic metabolic panel at admission. Vital signs were stable, and she was afebrile. Abdomen was soft, nontender and nondistended. The patient was planned for the operating room for management of fibroids. The patient presented to the operating room for scheduled abdominal myomectomy. The patient underwent an uncomplicated removal of uterine fibroids with general anesthesia. The estimated blood loss was 100 milliliters (mL). There was 1000 cubic centimeters (cc) of intravenous (IV) fluid given. The leiomyoma was sent to pathology. There is normal-appearing external genitalia with a fundal fibroid of 5 centimeters (cm) which was pedunculated. Normal-appearing ovaries and tubes were noted bilaterally. Following surgery, the patient was stable and contained on oral medication for postoperative pain.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient who was admitted for a planned uterine myomectomy for the indication of abdominal bloating, abdominal pain, infertility and menorrhagia. 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 single, simple myomectomy completed by laparotomy (Pfannenstil incision) under general anesthesia. The myoma was pedunculated on the fundus of the uterus. The surgery was uncomplicated. The surgical time for completion of surgery was only 1.6 hours. Thus, the surgery was completed in minimal time. There was no excessive blood loss with an estimated blood loss of 100 milliliters (mL). There was no damage to bowel, bladder, or other intra-abdominal structures. The goal length of stay for this procedure based upon the MCG guideline is Ambulatory or 2 days postoperative. 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 from an ambulatory stay on the date of admission based upon the documentation reviewed. Based on review of the medical documentation and the MCG Health Guidelines, there was no medical necessity for acute inpatient admission as the patient had no evidence for care that required acute inpatient admission as outlined by the Guideline. The patient could have been managed at a lower level of care status and met discharge criteria following the procedure.