Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemorrhagic Ovarian Cyst and Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female that presented to the Emergency Department with right lower quadrant pain and vomiting which began that morning. The patient began have menses one year prior. Last menstrual period was 2.5 to 3 weeks ago. The patient had normal vital signs in the Emergency Department. Physical examination showed right lower quadrant tenderness. White blood cell count was normal with left shift (78% neutrophils). All labs were within normal ranges. Ultrasound did not visualize the appendix. Pelvic ultrasound showed an enlarged right ovary containing a complex structure consistent with a hemorrhage ovarian cyst. Flow was identified in both ovaries. CT (computed tomography) scan of the abdomen and pelvis done showed a right ovarian cyst. There was a moderate amount of free fluid in the pelvis not seen on the earlier ultrasound. Torsion or a dermoid lesion could not be excluded. Repeat ultrasound done after the CT scan showed blood flow to both ovaries. The patient received antiemetic medication and intravenous fluids in the Emergency Department. The Pediatric Surgeon saw the patient in the Emergency Department and recommended "admit for observation overnight." The surgeon stated that if the patient worsened overnight, she may require diagnostic laparoscopy. The admitting diagnosis was ruptured ovarian cyst. 

The patient was admitted to acute inpatient level of care to receive antiemetic medication and for pain control. Pain control was accomplished with intravenous and then oral acetaminophen. No narcotics were given. The patient was improved the following morning and was discharged. 

The patient was approved for observation level of care. The hospital has appealed the denial of the acute inpatient level of care which is the subject of this review. The hospital's appeal applied MCG Health Guideline for Abdominal Pain, Undiagnosed, Pediatric. The cited guideline is severe pain with pain control not achieved during observation care and inability to maintain oral hydration. The hospital's agent states the patient was tachycardic with a pulse of 104 beats per minute and tachypneic with a respiratory rate of 20. The patient continued with nausea after admission. On hospital day # 2, the pulse rate was 100 bpm which the hospital's agent reports as tachycardic. Hemoglobin dropped from 13.2 mg/dl on admission to 11.6 mg/dl. The patient was discharged home (hospital day # 2).

No. The "treatment" i.e., inpatient level of care was not medically necessary. The care rendered did not require acute inpatient level of care.

Ultrasound showed a complex cyst of the right ovary with blood flow to both ovaries. The appendix was not visualized. White blood cell count was not elevated but there was a left shift (elevated neutrophils). The patient had normal vital signs (the appeal letter states the patient was tachycardic with a pulse rate of 104 beats per minute which is considered within normal range for the patient's age). Physical examination showed tenderness in the right lower quadrant. Treatment in the Emergency Department included intravenous fluid bolus and a follow-up computed tomography scan. Computed tomography scan done showed a right ovarian cyst. There was a moderate amount of free fluid in the pelvis not seen on the earlier ultrasound. Torsion of the ovary could not be excluded. A repeat ultrasound was done after the computed tomography scan to rule out torsion which showed blood flow in both ovaries. The cyst was unchanged. The patient received antiemetic medication, intravenous fluids, and non-narcotic pain medication. Pediatric Surgery was consulted and recommended admit for observation due to ongoing pain and inability to tolerate oral intake. The patient was admitted to Pediatrics. Regular diet was ordered the following morning and the patient was transitioned from intravenous to oral Tylenol. The patient was discharged home the following morning. The care rendered did not require acute inpatient level of care.

Yes. The health plan acted reasonably with sound medical judgment in denial of the acute inpatient level of care. The patient could have been treated at a lower level of care without adversely affect the quality of care delivered or endanger the patient's health or safety and would not compromise the best interests of this patient.

The patient was admitted to acute inpatient level of care in the evening after evaluation in the Emergency Department. The patient had 2 ultrasounds and a computed tomography scan which showed an ovarian cyst. The subsequent computed tomography and ultrasound suggested rupture of the follicle and no findings of compromised blood flow to the ovary (torsion).

The hospital by and through its agent cites the MCG Health Guideline for Abdominal Pain, Undiagnosed, Pediatric. In fact, the patient was diagnosed with a ruptured ovarian cyst for which the more appropriate Milliman Guideline for Obstetric and Gynecological GRG (general recovery guideline) states inpatient admission may be indicated for condition, symptom or finding for which observation has failed or is not considered appropriate. The guideline refers to General Pediatric Admission criteria which were not met. Even if laparoscopic evaluation were required, the guideline considers laparoscopic surgery for excision of adnexal mass or ovarian disease (for example, cyst) requiring removal as ambulatory.

Furthermore, the cited guideline for Undiagnosed Abdominal pain was not correctly applied. The guideline states inpatient level of care is necessary for severe pain requiring acute inpatient management. The patient's pain would not be considered severe as she was only receiving non-narcotic medication for pain. Furthermore, the guideline states inpatient care is necessary for "inability to maintain oral hydration that persists after observation care." In fact, the patient was able to tolerate regular diet the following morning within the observation level of care period. The guideline also states that discharge from observation care is appropriate for pain absent or managed on hospital day # 2 which was achieved (hospital day # 2). The hospital's agent states the patient was tachycardic with a pulse of 104 beats per minute and tachypneic with a respiratory rate of 20. (Normal heart rate for this patient's age is < [greater than] 120 beat per minute / normal respiratory rate is < [greater than] 30 beat per minute). The patient achieved discharge status within the approved observation period. The acute inpatient level of care was unnecessary. The care the patient would have a received at a lower level of care i.e. (that is), observation would have been identical to the care rendered.