Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient presented to the hospital emergency room (ER) with complaints of abdominal pain. She was noted to have a positive pregnancy test with a human chorionic gonadotropin prove (hCG) of 424.2 and stable vital signs. She remained afebrile. The patient was complaining of abdominal pain in pregnancy and reported she had vaginal bleeding for approximately 2 weeks. She was status post childbirth and was breast-feeding. The patient was evaluated in the emergency department on the day prior and found to be pregnant with an hCG in the 700's. At that time, she had an ultrasound that did not demonstrate an intrauterine pregnancy. Patient reported that she had acute onset of severe right lower quadrant pain with persistent bleeding at presentation. The patient was noted to have positive Pregnancy test and pelvic pain and underwent an ultrasound. The patient was admitted to the OB/GYN service and was to go to the operating room for a ruptured right tubal ectopic pregnancy with hemoperitoneum.

The acute inpatient admission was not medically necessary at the acute inpatient level of care status for this patient. The American College of Obstetrics and Gynecology (ACOG) recommend that the care for salpingectomy for ectopic pregnancy should be an ambulatory level of care and does not require acute inpatient medical care. The surgical care should require the following criteria to be met for discharge to home:
Successful, uncomplicated laparoscopic surgery. There were no complications noted.
No evidence of bleeding - there was no evidence of bleeding in this case and there was only 110 mL of total blood loss. The patient had a stable hemoglobin and hematocrit and did not require any transfusion. 
Afebrile - the patient was afebrile for the entire hospitalization.  
Pain absent or managed - pain was managed with oral medications in this case. 
Discharge plans and education understood - There were no limitations noted to preclude discharge planning and education in this case. 
Oral hydration, medications, and diet - this was present in this case postoperatively with resumption of a regular diet and oral medications. 
Ambulatory - the patient was ambulatory. 
In this case, the American College of ObGyn recommends implementation of Enhanced Recovery After Surgery (ERAS) pathways. The basic principles of ERAS include attention to the following: preoperative counseling and nutritional strategies, including avoidance of prolonged perioperative fasting; perioperative considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis. Benefits of ERAS pathways include shorter length of stay, decreased postoperative pain, and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction. Implementation of ERAS protocols have not been shown to increase readmission, mortality, or reoperation rates. In this case, the minimal invasive approach to surgery and normal recovery would be anticipated to result in a lower level of care after surgery. Based upon a review of the medical records and the procedures and course of care on, there would be no medical necessity for acute inpatient level of care for a postoperative stay after right salpingectomy due to ectopic pregnancy.