Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: Inpatient admission

The proposed inpatient admission was not medically necessary.

The patient presented with signs and symptoms of right lower quadrant pain and urinary tract infection. The patient was referred by urgent care because there was right lower quadrant pain upon palpation. The pain was sharp and constant with burning upon urination. The patient has a history significant for dysuria and frequency. 

Vital signs were normal with a heart rate at 77 and normal respiration. The urine analysis (UA) was positive and the electrolytes and complete blood count (CBC) were normal. The abdominal pelvis computed tomography (CT) scan without intravenous (IV) contrast revealed no evidence of kidney stones and the appendix was not visualized; however there were no secondary signs of acute appendicitis. The patient was admitted to surgery for nothing by mouth (NPO), IV fluids, IV antibiotics for her UTI, and evaluated by gynecology (GYN) later that evening. Pelvic ultrasound the following day revealed free fluid in the cul-de-sac consistent with a ruptured ovarian cyst.  The patient was discharged the following morning on oral antibiotics. 

The patient was admitted with a diagnosis of urinary tract infection which was documented by history and urinalysis. CT scan was performed secondary to her physical exam and essentially ruled out an acute surgical diagnosis. Furthermore, the patient did not have any signs and symptoms of sepsis that warranted inpatient hospital stay. The patient was afebrile with normal vital signs and normal laboratory evaluation. 

Rupture of an ovarian cyst is a common occurrence in women of reproductive age. Physiologic cysts, such as a follicular cyst or corpus luteal cyst, or pathologic cysts may rupture (endometriomas, cystic components of benign or malignant neoplasms). In the normal menstrual cycle, the physiologic rupture of small follicular cysts that occurs with every ovulatory cycle is not typically clinically significant. This cyclic event is generally asymptomatic or associated with mild mid-cycle pain (also referred to as mittelschmerz).

Ovarian cyst rupture results in release of cyst fluid or blood that may irritate the peritoneal cavity. Dermoid cysts contain sebaceous fluid, hair, fat, bone, or cartilage, and rupture of these cysts results in severe peritoneal irritation. Surgical management is usually required for rupture of a dermoid cyst.

Most women with a ruptured ovarian cyst may be managed with observation, analgesics, and rest, but some women require surgery. Decisions regarding management are based upon patient characteristics, including the severity of symptoms, presence of ongoing bleeding and/hemodynamic instability, and the presumptive histologic diagnosis.

For women with an uncomplicated rupture of an ovarian cyst, observation is preferred rather than surgical intervention. There are no data comparing these two strategies in this patient population, but if there are no concerns about ongoing brisk bleeding or infection or malignancy, the risks of surgery are not warranted.

These patients can usually be managed as outpatients as long as they are hemodynamically stable without a significant drop in hematocrit. They should return for increased pain or lightheadedness. Oral analgesia is given as needed. Non-hemorrhagic cyst fluid is usually resorbed within 24 hours and symptoms typically resolve within a few days. Follicular and corpus luteum cysts account for most of these cases.

This patient could have been managed at a lower level of care when it was clearly a non-surgical diagnosis.