Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enlarged fibroid uterus
Treatment: Inpatient admission
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult female with an enlarged fibroid uterus who desires fertility. She has been seeing reproductive specialists who recommended myomectomy prior to in vitro fertilization. She was previously on Depo-Provera but stopped and was having heavier bleeding. She has a history of a provoked venous thromboembolism and thyroid disease. She was taken to the operating room for elective laparoscopic myomectomy. She had an enlarged fibroid uterus. The procedure was uncomplicated. Estimated blood loss (EBL) was 500 cubic centimeters. She was admitted overnight for anticoagulation and serial blood counts. Her pain was rated a 5/10. She received intravenous Tylenol and intravenous Dilaudid. She received 5000 units of heparin. On postoperative day 1, she was ambulating, voiding, and tolerating diet. Her pain was controlled. Her blood levels were stable with a hemoglobin on 8.2. She was discharged home within 24 hours. The inpatient admission was denied coverage by the health plan as not medically necessary. This is being appealed.

The inpatient admission was not medically necessary.

According to 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 [enhanced recovery after surgery] 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 [enhanced recovery after surgery] program requires collaboration from all members of the surgical team. Successful ERAS [enhanced recovery after surgery] 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 [enhanced recovery after 
surgery] pathways should be strongly encouraged within institutions. (2)" An outpatient observation bed is an alternate level of healthcare comprising 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 fibroid uterus. After surgery, she was not ready for discharge same day due to her history of a blood clot and needing anticoagulation. She required observation and nursing care to assist with her medical management. This could have been done in an observation status. By post-operative day 1, the patient was ready for discharge requiring a 24-hour stay. Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.