Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian cyst 

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial upheld.

This patient is a female with a history of ovarian cyst and previous gastric bypass surgery. She presented for a scheduled exploratory laparotomy and diagnostic laparoscopy for pelvic pain. The plan as per ASU was to remove the cyst on the right ovary. Vital signs were stable. The laparoscopy was unsuccessful due to previous abdominoplasty and an exploratory mini laparotomy was performed under general anesthesia. A small ovarian cyst and a moderate amount of adhesions were noted. There were no complications during the procedure, and she was transferred to PACU. Pre-operative labwork revealed a white blood count (WBC) of 6.01, Hct 34.6.

Post-operative note showed the patient was resting comfortably with no new complaints. The patient was tolerating clear liquid. Vital signs were stable. The abdomen was soft and non-tender and non-distended. The plan was to advance diet to regular after flatus and out of bed in the morning. A subsequent progress note indicated the patient as resting comfortably and voiding without difficulty. The patient was tolerating regular diet. The note indicated possible discharge to home.

Based upon the records provided the insurer that the patient did not require acute inpatient admission as the patient could have been cared for based upon an observation status. The patient could have been observed for 23 hours and then discharged. According to MCG Inpatient and Surgical care- 23rd Edition Ambulatory Surgery Discharge and complications: common complications and conditions CCC: CCC-044 (ISC) clinical indications for inpatient care include: Surgery or procedure performed on ambulatory basis may require inpatient stay for 1 or more of the following: Preoperative situation, condition, or finding that warrants inpatient stay as indicated by 1 or more of the following: Inpatient care needed for preoperative disease or condition; Emergent procedure; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. There were no indications in this case for inpatient care as the patient could have been monitored in an observation status. 

Furthermore, as per MCG Inpatient and Surgical care- 23rd Edition Laparotomy for gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy ORG: S-450 (ISC), the operative status criteria is ambulatory for : nonelderly (younger than 65 years) patients undergoing elective simple (malignancy or infection not suspected) myomectomy, oophorectomy, or tubal procedures performed via minilaparotomy (incision less than 5 cm in length). Some nonelderly (younger than 65 years) patients without comorbidities requiring long-term (e.g., more than 24 hours postoperatively) care undergoing elective simple (malignancy or infection not suspected) standard incision laparotomy for excision or destruction of intra-abdominal tumors, cysts, or endometriomas, myomectomy, oophorectomy, lysis of adhesions, salpingectomy, ovarian transposition, ovarian biopsy, ovarian wedge resection, ovarian cyst drainage, ovarian cystectomy, or surgical treatment of ectopic pregnancy.

To summarize, the inpatient hospital admission from was not medically necessary at the acute care level and based upon these findings the health care plan did act reasonably and with sound medical judgment.  

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.