Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder-Uterine Fibroids
Treatment: Inpatient Hospital. 
The insurer denied the inpatient hospital admission for medical necessity. 
The denial was upheld. 

This patient is a female, gravida (G) 1 para (P) 1, who was sent to the emergency department for ultrasound findings of a myoma. She had mild abdominal pain in the lower abdomen for 2 weeks, which she described as constant. This was not associated with nausea, fever, chills, or pain. She had no chest pain or shortness of breath. The patient had a past obstetric history noted for a term vaginal delivery times () 1. The patient's review of systems was noted to be positive for abdominal pain. All other systems were negative. The patient had an appointment for surgery that same week, but because of ultrasound findings of a pyomyoma she was sent for intravenous (IV) antibiotics.

The patient's examination was noted to be normal. A transabdominal ultrasound noted a posterior myoma measuring 12 x 10 centimeters (cm) with no free fluid appreciated. 
The blood count was also normal with a hemoglobin of 14.2, hematocrit of 42.9, and platelets of 255. The white blood cell count was normal.

The patient was seen and evaluated with no issues overnight and reported that her abdominal pain was improved. She did report some calf tenderness and reported that this pain was similar to when she had a deep vein thrombosis (DVT) in the past. For this reason, the patient did undergo a formal evaluation of the lower extremities by ultrasound which were noted to be negative.

The patient had undergone a magnetic resonance imaging (MRI) scan which noted a large, broad-based pedunculated subserosal myoma arising from the right anterior lateral uterine wall containing extensive peripheral cystic and partially centric necrotic components and measured 18.5 x 16.4 x 13.1 cm. The myoma was well encapsulated without enhancing septate or enhancing fluid. The right ovary was displaced by a small myoma of 2.1 x 0.7 cm. The left ovary was normal size at 2.7 x 1.8 cm. The patient was discharged to home with follow-up in the outpatient setting.

At issue is the inpatient hospital admission for medical necessity.

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

The requested health service treatment of inpatient hospital admission was not medically necessary for this patient.

In this case, the patient was noted to have a long standing myoma that was partially degenerating. There was concern for a pyomyoma but there was no finding to support that the patient had an infection. There was no pain on admission with a normal white count and normal examination. There was no fever or tachycardia. The imaging in this case was reassuring without any concerns. Pyomyoma, or suppurative leiomyoma, is a rare complication of uterine fibroids. It occurs most commonly in the setting of pregnancy, the immediate postpartum period, or postmenopausal status. The most likely cause of pyomyoma is vascular compromise followed by bacterial seeding from direct, hematogenous, or lymphatic spread. In this case, the patient had no risk factors, abnormal labs, abnormal exam, or imaging to support the need for antibiotics or the acute inpatient level of care.

Thus, the inpatient hospital admission was not medically necessary.