Appeal type: Medical necessity
Decision: Upheld

Genitourinary/ Kidney Disorder/Other/Surgery on ovaries (torsion of left ovary)
Inpatient Hospital/Inpatient emergency admission

The health plan has denied the requested treatment as not medically necessary. The health plan's determination is upheld. 

In this case, the patient presented to the emergency room (ER) as a female with a history of anemia and an ovarian cyst with left lower quadrant pain that had onset at 5 AM that morning. She was noted to have dyspareunia recently. She reported the pain to be worse with walking, and the pain was at an 8/10 at worst. She denied any nausea, vomiting, diarrhea, blood in stool, dysuria, urinary frequency, vaginal discharge, bleeding, or spotting. On examination, the patient was noted to have left lower quadrant (LLQ) tenderness without rebound or guarding. She had left adnexal tenderness on exam with no palpable masses or cervical motion tenderness. The patient was noted to have a history of a left ovarian cyst, and, given this pain, there was consideration of torsion and possible cyst rupture. An Obstetrical/Gynecological (ObGyn) consultation was ordered. Laboratory studies were reassuring with a normal white count, normal hemoglobin, and normal hematocrit. There was also a normal basic metabolic panel (BMP). A transvaginal ultrasound noted findings consistent with left adnexal torsion. There was a 12 centimeter (cm) left adnexal cyst also noted. The patient was consented for diagnostic laparoscopy and made nothing by mouth (NPO). She was taken to the operating room (OR) urgently.

An examination of the patient under anesthesia in the operating room revealed normal appearing female genitalia with copious discharge consistent with bacterial vaginosis. There was a small anteverted uterus with anterior fullness. On laparoscopy, there was a 13 cm left ovarian cyst with torsion times 360 around the pedicle. The left ovarian tissue was otherwise normal in appearance without any duskiness or engorgement. There was normal right adnexa and a small anteverted uterus appreciated. A large ovarian cyst was peeled from the cyst, bed intact and then drained with 500 cubic centimeters (cc) of clear serous fluid. The cyst was sent for pathology. Anesthesia was uncomplicated. Her estimated blood loss was 10 milliliters (mL) with 75 cc of urine output and 1000cc of fluid replacement. The patient was discharged to home in stable condition with afebrile status and with followup scheduled in the outpatient setting.

At issue is the medical necessity of the inpatient emergency admission.

I uphold (in whole) the health plan's determination of medical necessity in this case.

Based upon a review of the medical records, the peer reviewed literature on ovarian torsion, and the Milliman Care Guidelines (MCG), there would not be medical necessity for admission to acute inpatient level of care for the performance of laparoscopic ovarian cystectomy and detorsion due to ovarian torsion as presented in the medical record.

In this case, the patient was known to have an ovarian cyst and presented from home with classic signs of ovarian torsion. Imaging by ultrasound also supported this diagnosis, and the patient was taken to the operating room where an uncomplicated ovarian cystectomy and detorsion was completed with minimal blood loss (10 cc or less) and no complications. There were no complications of infection, metabolic condition, surgery, bleeding, hypotension, or co-morbid conditions affecting surgical outcome.