Appeal type: Medical necessity
Decision: Upheld

The patient is a gravida (G) 0 female who presented to the emergency department with a one-day history of right lower quadrant pain. The patient stated she noted a pain described as aching in the right lower quadrant around 7 AM on the day prior. She went to work but continued to have right lower quadrant pain. She stated the pain caused her to be uncomfortable all day and she had tried Motrin twice on the day prior. She reported last eating at midnight. She came to the emergency department due to the pain being worsening overnight. She stated that she could not get comfortable in bed and the pain was occasionally sharp with ambulation. The patient denied fever, chills, nausea, vomiting, diarrhea, headache, constipation, dizziness, syncope, chest pain, palpitations, shortness of breath, dysuria, urgency, frequency or vaginal bleeding.

The CT scan of the abdomen and pelvis showed an enlarged adnexa of 6 centimeter (cm). The patient was hemodynamically stable. On physical exam the patient appeared comfortable with last received a Tylenol 4 hours prior. Given the size of the cyst a plan was made for cystectomy to be performed due to the risk for intermittent torsion. Ultrasound was also performed and confirmed this to be an ovarian cyst. There was no evidence of acute appendicitis on CT scan. The patient was consented for a diagnostic laparoscopy with right ovarian cystectomy. The patient signed all consents and plan was made to take her to the operating room for evaluation. The patient was taken to the operating room with a diagnosis of adnexal cyst and underwent a laparoscopic right salpingectomy. Specimen demonstrated a right paratubal cyst and right fallopian tube. The estimated blood loss was 25 milliliter (mL). Intravenous (IV) fluids of 1000 cubic centimeter (cc) of lactated Ringer's was given. Urine output was 275 mL. At the time of surgery there was an 8 cm right paratubal cyst noted to be torsed multiple times with a normal-appearing left and right ovary. There was normal-appearing left fallopian tube and a grossly normal-appearing uterus and bowel. The procedure was completed without complications. The patient had Dermabond placed over the skin incisions.

Following surgery, the patient was noted to have stable vital signs, managed pain control on oral medications, and well appearing incisions. There were no complications noted. The patient remained afebrile and with normal vital signs. There were no limitations for communication of postoperative care instructions. She was discharged to home with outpatient follow-up scheduled.

The health plan's determination is upheld.

The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient who was admitted for a laparoscopic adnexal cystectomy due to possible intermittent torsion. The Milliman Care Guidelines (MCG) Guideline entitled "Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy" were reviewed in concert with the medical records in this case. The surgical procedure was noted to be a unilateral salpingectomy due to paratubal cyst and was completed laparoscopically under general anesthesia. The surgery was uncomplicated. However, the surgical time for completion of surgery was only 1 hour 19 minutes. Thus, the surgery was completed in minimal time. There was no excessive blood loss with an estimated blood loss of 25 mL. There was no damage to bowel, bladder, or other intra-abdominal structures. 
Based on review of the medical documentation and the Milliman Care Guidelines, there was no medical necessity for acute inpatient admission as the patient had no evidence for care that required acute inpatient admission as outlined by the Guideline. The patient could have been managed at a lower level of care.