Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient stay
The insurer denied: Inpatient stay
The denial is upheld

The patient is an adult female who presented to the emergency department with ten out of ten abdominal pain. She had been having pain for months, but it acutely worsened. She had blood work which revealed elevated white blood cell count. She had 
imaging revealing a ten-centimeter complex left ovarian mass. She had elevated cancer antigens. She was given intravenous access (IV). She required morphine and Toradol for pain control. She was admitted and placed as nothing by mouth (NPO) overnight. She was continued on intravenous fluids. Gynecology oncology was consulted due to the elevated cancer antigens. The next day, the patient was taken to the operating room and underwent a robotic assisted laparoscopic hysterectomy, left sapling-oophorectomy and right salpingectomy. The procedure was uncomplicated and after acute recovery in the post anesthesia care unit she was transferred to the floor. She was continued on intravenous Tylenol and Toradol. Her pain had improved, and her vitals were stable. She was discharged home the next day with follow up.
The inpatient hospital stay is denied as not medically necessary. This is being appealed.

The proposed treatment 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 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 program requires collaboration from all members of the surgical team. Successful ERAS 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 pathways should be strongly encouraged within institutions."
An outpatient observation bed is an alternate level of healthcare compromising of 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 question was taken to the operating room and underwent an uncomplicated procedure for a pelvic mass. After surgery she was not ready for discharge same day due to her continued pain. She required observation and nursing care to assist with her ambulation and medical management of her pain. This however could have been done in an observation status. The care provided did not require acute inpatient care. By post-operative day #1, the patient was ready for discharge requiring less than a 24 hour stay post-surgery. Therefore, the patient did not require an acute inpatient stay as the same care could have been provided under an observation status.