Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Stomach Pain. 
Treatment: Inpatient Hospital Stay. 

The health plan denied: Inpatient Hospital Stay. 
The determination is upheld. 

This patient is a female who was admitted to the acute inpatient level of care for a diagnosis of abdominal pain and nausea in the setting of a ruptured ovarian endometrioma. The patient presented to the hospital via Emergency Medical Services (EMS) with lower abdominal pain, nausea, and vomiting. She had stable vital signs with a temperature of 98.8 Fahrenheit, a blood pressure of 114/77 millimeters of mercury (mmHg), a heart rate of 96 beats per minute (bpm), and a respiratory rate of 18/minute, with 98% oxygenation on room air. Her pain was reported at 10/10. The patient was alert and awake. The abdominal pain woke her from sleep 30 minutes earlier. She felt that this was similar to suprapubic pressure with sharp pains following. She had nausea and vomiting with this onset. She had no fever or chills. She had no prior history of similar pain and denied dysuria, vaginal discharge, or abnormal bleeding. 
She had no significant past medical history. She had prior myringotomy tubes placed. She was a non-smoker. Review of systems was noted for difficulty urinating and abdominal pain. The exam noted tenderness to palpation in the right lower quadrant (RLQ) and suprapubic guarding without rebound. The patient was ordered for an ultrasound. She was noted to have an adnexal mass with possible torsion. The labs were normal with normal white blood cell count, normal hemogram, and normal basic metabolic panel and liver functions. The right ovary had a heterogenous mass with moderate complex free fluid also noted. Moderate hemoperitoneum was noted. She was given morphine. Her vital signs remained stable. The patient was taken to the operating room (OR) and underwent a Laparoscopic right ovarian cystectomy. The uterus was 6 weeks in size and normal. There were normal upper abdominal findings. The patient had 100 milliliters (mL) of hemoperitoneum on exam. The cyst was removed, and the right ovary was covered with Intercede. The estimated blood loss was 25 mL. The patient had a normal urine output of 150 mL. The patient was given intravenous (IV) fluids. The postoperative course was uncomplicated. The patient was noted to continue to be afebrile with well healing surgical sites and normal vital signs. She had no active issues and was meeting all postoperative goals with resolution of pain. Postoperative Day 1, the patient underwent a repeat complete blood count (CBC) that was stable. Her vital signs were stable. Her pain was controlled on oral medications. She was on a regular diet. The patient was passing flatus and voiding without difficulty. She was then discharged home with follow-up in the outpatient setting. 

At issue is the medical necessity of the inpatient admission. 

The health plan's determination of medical necessity is upheld in whole. 

The inpatient admission was not medically necessary at the acute inpatient level of care. The Milliman Care Guidelines (MCG) Guideline entitled "Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy," American College of Obstetricians and Gynecologists (ACOG) Adnexal Mass management guidelines, and surgical recovery literature were reviewed in concert with the medical records in this case. The surgical procedure was noted to be a unilateral right laparoscopic ovarian cystectomy and peritoneal biopsy completed laparoscopically under general anesthesia. The surgery was uncomplicated. The surgical time for completion of surgery was minimal. There was no excessive blood loss. There was no damage to bowel, bladder, or other intra-abdominal structures. The determination of the length of the necessary stay is based upon the optimal recovery course. The patient was noted to meet all aspects of care required for discharge on the date of admission.