Appeal type: Medical necessity
Decision: Upheld

The patient is a female who was complaining of vaginal bleeding when she presented to the emergency department. Patient reported vaginal bleeding for the past 12 weeks. She reported pain of 5/10. She had no aggravating or relieving factors. The patient was noted have a past medical history of abnormal findings on diagnostic imaging of her abdomen including the retroperitoneum. Her past surgical history included a dilation and curettage. The patient was a non-smoker and had no allergies. Her home medications included folic acid taken daily. At presentation, she was afebrile at 97.7F. Her heart rate was 68 with a blood pressure of 109/69. Oxygen saturation was 100% on room air. The patient's weight was 139.9 pounds. Her physical exam was noted to be normal. The genitourinary exam was deferred. The abdomen was soft, nontender and there is no guarding present. The patient was admitted from the emergency department to the obstetrics/gynecology (OB/GYN) service.

During the hospitalization, the patient specifically underwent a dilation and curettage and hysteroscopy under general anesthesia. The patient had estimated blood loss of 5 milliliter (mL) at the time of surgery. The surgical procedure was noted to be uncomplicated. Bloody debris from the endometrial cavity was evacuated and there were no intracavitary lesions noted. A clean cavity with negligible bleeding was noted at the case conclusion. The patient had no complications during the course of the surgery. The patient was discharged to home following the surgery. The anesthesia documentation noted the patient's vital signs remained stable without any complications of anesthesia. The patient was afebrile. The surgery start time was 3:07 PM and the surgical stop time was 3:15 PM. Endometrial curettings were sent to pathology for identification following the procedure.

The health plan's determination is upheld, in whole. 

In review of this case, the patient had a dilation and curettage for menorrhagia in the setting of no medical comorbidities and no evidence of anemia. She was noted to be stable with regard to her vital signs. Thus, this admission from the emergency department is focused on the bleeding / menorrhagia present and management. Initial evaluation of the patient with acute abnormal uterine bleeding (AUB) should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability. This was not present in this case. If the patient was hemodynamically unstable or has signs of hypovolemia, intravenous access with a single or two large bore intravenous lines would be initiated rapidly as should the preparation for blood transfusion and clotting factor replacements. Given this was not present, this was not an indicated step in her management.

After the initial assessment and stabilization, the next step is to evaluate for the most likely etiology of acute AUB so that the most appropriate and effective treatment strategy to control the bleeding can be chosen. In this case, an ultrasound noted a normal endometrium and the patient was monitored. She was noted to have ongoing bleeding and a dilation and curettage was planned. The etiologies of acute AUB, which can be multifactorial, are the same as the etiologies of chronic AUB. The Menstrual Disorders Working Group of the International Federation of Gynecology and Obstetrics proposed a classification system and standardized terminology for the etiologies of the symptoms of AUB, which has been approved by the International Federation of Gynecology and Obstetrics executive board and supported by the American College of Obstetricians and Gynecologists (ACOG). With this system, the etiologies of AUB are classified as "related to uterine structural abnormalities" and "unrelated to uterine structural abnormalities" and categorized following the acronym PALM-COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not otherwise classified. Determining the most likely etiology of acute AUB is essential for choosing the most appropriate and effective management for the individual patient and is accomplished by obtaining a history, performing a physical examination, and requesting laboratory and imaging tests, when indicated.

The Milliman Care Guidelines (MCG) Guideline entitled "Obstetric and Gynecologic Disease GRG" was reviewed in concert with the medical records in this case. This guideline lists the specific criteria to be considered when an inpatient admission is medically necessary. The specific criteria in this case are entitled "uterine bleeding with high-risk features indicated by one or more of the following: active major hemorrhage, coagulopathy with active bleeding, gestational trophoblastic disease, pregnancy related bleeding, or severe anemia. In this case, the patient did not have an active major hemorrhage and the bleeding is noted to be stable and not acute resulting in abnormal vital signs or cardiovascular collapse. The patient had normal pulse rate and stable vital signs. There was no anemia present. There was no coagulopathy as her labs were normal. She also had no severe anemia (< 6 g/dL). In this case, the patient had no evidence of anemia by her complete blood count. Severe anemia in the MCG guideline is defined as that which is accompanied by altered mental state, chest pain, exertional dyspnea, or syncope. There can also be inadequate perfusion. This can also be seen with transfusion or volume replacement where there is in effective resolution of tachycardia or orthostatic vital sign changes. In this case, the patient had no tachycardia or orthostatic vitals. She had no chest pain, dyspnea, syncope or anemia. Thus, she did not meet the criteria for severe anemia. Rather, the patient had menorrhagia. Thus, the patent would be expected to be managed at an alternative level of care than inpatient in this case. Inpatient care would not be medically necessary for the treatment of the patient's condition as presented in this case.