Appeal type: Medical necessity
Decision: Upheld

Diagnosis - Gynecological 
Inpatient Hospital 

The patient is female Gravida (G) 6 Para (P) 3 Living (L) 3 who presented with fever and lower abdominal pain for 2 days status post suction dilation and curettage (D&C), for admission to acute inpatient level of care. The patient was noted to have a suction dilatation and curettage performed on by her private obstetrics/gynecology (OB/GYN) provider after failing a medical termination of pregnancy. The patient reported an uncomplicated surgery and was discharged on ciprofloxacin which she had been taking. She reported mild bleeding since surgery but no foul-smelling or purulent discharge. She denied dyspnea, chest pain, cough, nausea, vomiting, anorexia, dysuria or constipation. The patient's obstetric history noted 3 prior full-term vaginal deliveries and 3 elective terminations of pregnancy by surgical procedure. Her medications included ciprofloxacin and ibuprofen. The patient reported no allergies. 

At presentation, the patient's temperature was 102.8 with a heart rate of 57-80. Her blood pressure was 104-119/41-53. Her oxygen saturation was 100% on room air and her respiratory rate was 20. The patient's heart was normal. The abdomen was soft and tender to palpation in the right lower quadrant and suprapubic region with no rebound or guarding. The patient was noted to have a normal complete blood count with a white count 4.2 with 85% neutrophils. Her hemoglobin was 10.9 with hematocrit 34.5% and platelets were normal at 161. A transvaginal ultrasound was performed which did not reveal any adnexal masses or free fluid. A pelvic exam was completed and noted a closed Os with trace vaginal bleeding on bimanual exam and there was no cervical motion tenderness. There is mild fundal tenderness and no adnexal tenderness. 

The aspartate aminotransferase (AST) was noted at 70 and the alanine aminotransferase (ALT) at 112 with a normal alkaline phosphatase. A basic metabolic panel was noted to be normal. The human chorionic gonadotropin (hCG) was 2494. The patient was given a diagnosis of sepsis of unspecified organism at admission. She was not adequately treated with the outpatient ciprofloxacin and was concerning for endometritis versus pelvic inflammatory disease. The endometrial stripe was thin with concerns for retained products of conception. The patient was admitted for intravenous (IV) antibiotics on Doxycycline, Flagyl and Ceftriaxone. The patient was to have her vital signs monitored and blood cultures and urine cultures performed. Repeat labs were planned for the morning. The patient was started on IV hydration and a regular diet. She was given heparin twice daily for deep vein thrombosis (DVT) prophylaxis. 

The health plan's determination is upheld. 

In this case, the care provided could have been provided at a lower level of care and did not require admission to acute inpatient level of care. There is no evidence that this was anything more than mild postpartum endometritis following termination of pregnancy. There was no tachycardia, sepsis or hemodynamic instability. The white count was normal with only 1% immature forms (bands) at presentation and there was no evidence of an acute abdomen. Thus, there would have been no indication for admission to acute inpatient level of care. The care provided in the form of IV antibiotics and IV fluids could have been offered at a lower level of care. In this case, the inpatient admission would not have been medically necessary as based upon a review of the medical records and the Milliman Care Guidelines (MCG) Care Guidelines.