Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission.
The denial is upheld in whole.

This patient is a  gravida (G)4 Para (P)4 who presented to the emergency department with right lower quadrant pain that worsened the prior night. She reported that the pain was 8 and 10 and had dizziness with standing. She had received previous methotrexate therapy for ectopic pregnancy. She had followed up with her obstetrics/gynecology (OB/GYN) provider on day 4 and day 7 for blood draws. The patient denied any nausea or vomiting, she had no chest pain or shortness of breath. She denied vaginal bleeding or discharge. The patient was noted to have a history of bilateral tubal ligation with a negative urine pregnancy test and was found to have a positive beta quantitative test when she presented with pain. Past medical history was negative. Past surgical history was noted for prior tubal ligation and shoulder surgery. The patient's family history was positive for diabetes in her mother. The patient was a nonsmoker. The subject under review is medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole.

The inpatient hospital admission was not medically necessary for this patient based on a review of the medical records and the Milliman Care Guidelines 23rd Edition entitled "Obstetrical and Gynecological Disease General Recovery Guidelines (GRG)", given the member's stable ectopic pregnancy status post laparoscopic excision with stable vital signs and minimal blood loss of 200 mL. The patient was noted to have abdominal pain in the setting of a right ectopic that had failed methotrexate therapy and had a known diagnosis of ectopic pregnancy from a prior emergency room (ER) visit. The patient was noted to have normal vital signs with no evidence of hemodynamic instability at presentation or during her hospitalization. Surgery was completed in an uncomplicated fashion for the ectopic pregnancy via laparoscopy. There were no surgical complications, and the surgery was completed by laparoscopy. The MCG guidelines would find that the surgical procedure of laparoscopic management of ectopic pregnancy is necessary for the ectopic in this case, however this could have been managed at a lower level of care status. There is no medical necessity for inpatient level of care for laparoscopic management of ectopic pregnancy in this case. The MCG Care Guidelines General Recovery Guidelines 23rd Edition entitled "Obstetric and Gynecologic Disease GRG" and "Obstetric and Gynecologic Surgery or Procedure GRG" state that admission to the inpatient level of care would be medically necessary for hemodynamic instability, infection, active major hemorrhage, coagulopathy, severe anemia, or pregnancy beyond 23 weeks. None of these factors were present in this case. The patient had minimal bleeding with the procedure of 200 mL and had no complications of the procedure. She was never unstable and had normal pulse and blood pressure. There was no hemodynamic instability present. There was no severe anemia or active hemorrhage with coagulopathy and complete blood counts remained stable. There was no hemodynamic instability or infection present with normal vitals, white count, and normal complete blood count. There was no fever or sepsis noted. Finally, the pregnancy was not beyond 23 weeks gestation. The patient could have been managed at a lower level of care status. After reviewing the medical records in concert with these guidelines, there is no medical necessity for acute inpatient admission.