Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient presentation had a normal blood pressure 131/88 with a heart rate of 80. Her temperature was afebrile at 97.7 Fahrenheit (F). Her oxygenation was 98% on room air. The patient had a negative urine pregnancy test and was noted to have a normal urinalysis. There was no evidence of infection. White blood cell count was normal at 9.5. Patient had normal hemoglobin of 13.3 with hematocrit 39.7. Platelets were also normal at 272. The patient had a comprehensive metabolic panel which was also normal with normal liver function and normal urinalysis. The patient's blood type was B+ with a negative antibody screen. The patient was given a diagnosis of chronic pelvic pain with a for similar left adnexal cyst on CT (computerized tomography) scan. A plan was made for urine culture as well as an official ultrasound. The patient was noted to be soft with suprapubic tenderness on abdominal exam. The patient had left lower quadrant tenderness with no distention, rebound, or guarding. The patient declined going to the gynecologist (GYN) reporting for pelvic exam. The patient was noted to be a smoker. The patient was requesting pain medication and Benadryl to help sleep. She reported pelvic pressure and left for quadrant that was radiating to the vagina. She reported leaking of fluid when she moves around and pain during intercourse. The patient was given Toradol 30 milligrams (mg) for pain and Ambien for sleep. She was given intravenous (IV) Benadryl.  The patient was seen and evaluated at bedside and was noted have complaints of left flank pain and left lower quadrant pain. She was voiding, ambulating, and tolerating regular diet. Vital signs were stable and afebrile. The abdominal exam was soft with positive bowel sounds and suprapubic tenderness but with no distention or rebound or guarding. There is left costovertebral angle (CVA) tenderness. There is consideration for possible left pyelonephritis. The patient was seen  and noted to have a stable exam and she was still reporting abdominal pain. Vital signs were stable, and she remained afebrile. The patient was to follow cultures and a pelvic ultrasound was performed on this date of stay. She was taken to ultrasound for formal ultrasound. She remained stable and her IV was taken out of that time she did not want to have this replaced. The patient desired to go out to smoke and left the hospital against medical advice. The patient did not have a repeat ultrasound and her ultrasound in the emergency department was limited due to patient compliance with the exam. Vaginal culture and urine culture were negative. The subject under review is the medical necessity for the inpatient admission.

Based upon a review of the medical records and the peer reviewed literature on pelvic pain, the national Milliman Care Guidelines (MCG) Health Guidelines and recommendations of the American College of Obstetrics and Gynecology (ACOG), there would have been no medical necessity for admission to acute inpatient level of care in this case.


In this case, the patient had a simple cyst of 4 cm with normal blood flow. There was no documentation of an acute abdomen. Thus, the patient would not have required admission to acute inpatient level of care.