Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right ovarian mass
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with a large right ovarian mass. She underwent a laparotomy with right ovarian cystectomy, left salpingo-oophorectomy, and peritoneal washings. Intraoperative findings revealed a 20 x 18 x 15 centimeter mass from the left ovary. Intraoperative consult was done with gyn-oncology who recommended washings and removal of the left tube and ovary. Estimated surgical blood loss (EBL) was 30 cubic centimeters.
The patient tolerated the procedure well without complications. She was admitted overnight for serial vital signs, pain management, and abdominal exams. Her pain was controlled with intravenous Toradol and morphine. By postoperative day 1, she was tolerating regular diet, ambulating, voiding, passing flatus, and pain was controlled on oral regimen. She had stable post-operative labs. She was able to be discharged home on the next day with outpatient follow-up. The inpatient hospital stay has been denied by the health plan as not medically necessary. This is being appealed.

The Inpatient admission was not medically necessary.

According to the American College of Obstetricians and Gynecologists (ACOG), "The ERAS (enhanced recovery after surgery) principles represent an evidence-based approach to surgical management that challenges traditional surgical management paradigms. The use of ERAS [enhanced recovery after surgery] pathways has resulted in more rapid surgical recovery, shorter length of stay, greater patient satisfaction, and decreased costs when compared with traditional approaches. These benefits have been replicated across the spectrum of gynecologic surgeries, including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the ERAS [enhanced recovery after surgery] program requires collaboration from all members of the surgical team. Successful ERAS [enhanced recovery after surgery] 
pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems, and the use of ERAS [enhanced recovery after 
surgery] pathways should be strongly encouraged within institutions." An outpatient observation bed is an alternate level of health care comprising short stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient. The patient in this case was taken to the operating room and underwent an uncomplicated procedure for a large adnexal mass. After surgery she was not ready for discharge due to need for pain management and serial vital signs. She required close monitoring and nursing care to assist with her ambulation and medical management of her pain. This could have been done in a lower level of care. By post-operative day 1, the patient was ready for discharge requiring less than a 48 hour stay. Therefore, the patient did not require an acute inpatient stay as the same care could have been provided with the same outcome at a lower level of care. Therefore, the requested health service was not medically necessary.