Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Cyst.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is: Upheld.

The patient is a gravida (G) 0 female who presented to the hospital with complaint of abdominal pain. The patient was noted to have a temperature of 97.8 Fahrenheit (F) with a blood pressure 118/81 and a heart rate of 70 with respirations of 16. The patient was noted to have unlabored breathing and was able to communicate her complaint of abdominal pain. She was ambulating with steady gait and complained of lower abdominal pain with nausea and vomiting and burning with urination since early morning. She denied any diarrhea, abdominal tenderness to touch or other complaints. She had no recent travel. She had onset of right lower quadrant abdominal pain associated with urinary urgency, hematuria and flank pain at early morning. She stated the symptoms were waxing and waning with associated nausea. She was unable to get comfortable. She had no sick contacts or antibiotic use. The patient denied chest pain, shortness of breath, upper respiratory symptoms or gynecologic symptoms. She was a nonsmoker and had no significant past medical or surgical history. The plan was made for diagnostic laparoscopy with evacuation of hemoperitoneum and possible ovarian cystectomy. The patient was taken to the operating room where she underwent evaluation by laparoscopy which noted 700 cubic centimeters (cc) of hemoperitoneum that was evacuated, and bleeding was noted from the right ovary. A cystectomy was performed, and the bleeding was cauterized with a Kleppinger. Surgi-Flo was placed over the cystic area and there was good hemostasis. The laparoscopic port sites were closed with 0 Vicryl. Estimated blood loss was 50 milliliter (mL) and an additional 700 cc of hemoperitoneum was evacuated. Following surgery, the patient remained stable with stable vital signs. Postoperative day 1, the patient was stable with stable vital signs. She was noted to be tolerating clears and passing flatus. She received 2 units of packed red blood cells due to blood loss. She was voiding without difficulty. Pain was controlled with oral pain medication. The patient denied nausea, vomiting, fever, chills, shortness of breath or chest pain. She had no dizziness or weakness. Vital signs remained stable, and the patient was discharged to home with follow-up in outpatient setting. The subject under review is the medical necessity for the inpatient hospital admission.

The inpatient hospital admission was not medically necessary for this patient given the diagnosis of hemorrhagic ovarian cyst with stable vital signs. The American College of Obstetricians and Gynecologists (ACOG) recommend that the care for ovarian cystectomy for hemorrhagic cyst does not require acute inpatient medical care as presented in this case. In this case, the minimal invasive approach to surgery and normal recovery would be anticipated to result in lower level of care status. In this case, the patient met the ability to have pain controlled with oral medications, tolerate regular diet, and ambulate. She had no limitations to understanding post operative instructions. Thus, she was eligible for lower level of care status for her care. Based upon a review of the medical records and the procedures and course of care there would be no medical necessity for inpatient hospital admission for a postoperative stay after ovarian cystectomy due to hemorrhagic ovarian cyst.