Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female transferred by ambulance with a three week history of worsening and progressive abdominal pain. The patient has a history of ovarian cyst which has been followed with serial ultrasounds for several months. Ultrasound at the outside hospital showed a 4.5 by 5.8 by 3.2 centimeter cyst of the left adnexa (ovary / fallopian tube). 

On arrival, the patient's vital signs were normal. Physical examination showed tenderness in the left lower quadrant. There was no abdominal distension and no guarding. White blood cell count was mildly elevated to 11,460 without left shift (52% neutrophils). All other labs were normal and tumor markers were not elevated. Treatment in the Emergency Department included intravenous fluid bolus and repeat ultrasound. Ultrasound showed a 4.8 by 2. 6 by 4.6 centimeter cyst with blood flow. The cyst was about the same size as when first diagnosed. Follow-up ultrasound was recommended in six weeks. Intermittent torsion "should be excluded on clinical grounds." The patient was admitted to Pediatrics at the acute inpatient level of care. The patient was made nothing by mouth (NPO), administered intravenous fluids, and ordered for pain medication. Regular diet was ordered that morning. Pediatric Surgery resident noted the patient had been added onto the schedule for that day versus outpatient in one week. It was subsequently determined there was no surgical urgency and scheduled surgery in one week for left ovarian cystectomy. The patient was discharged home later that day. The total hospital length of stay was approximately 14 hours.  

The acute inpatient level of care was denied as it was determined to not be medically necessary.  This review is for an appeal of the denial of the inpatient level of care.  The hospital, through its registered nurse (RN) agent, states that the patient's condition required inpatient level of care and that Milliman Care Guideline for Pediatric Admission Criteria were met for inpatient monitoring requiring inpatient level of care (preoperative optimization, testing and evaluation).  The agent states the patient required inpatient management for an ovarian mass which could not be safely managed at a lower level of care. Due to concerns of torsion, the patient was admitted for optimization for emergent surgery.


No, the inpatient level of care was not medically necessary. The care rendered did not require acute inpatient level of care.
The hospital, through its registered nurse (RN) agent, states that the patient's condition required inpatient level of care and that Milliman Care Guideline for Pediatric Admission Criteria were met for inpatient monitoring requiring inpatient level of care (preoperative optimization, testing and evaluation).  The patient did not require preoperative optimization since she already had received intravenous fluids at the outside hospital and surgery was contemplated for that day. Laparoscopic ovarian cystectomy is an outpatient surgical procedure with overnight stay in some cases. Laboratory testing and evaluation could have been done as an outpatient or done in the emergency room (ER) with the patient sent home with plans for surgery as was done the next day. The agent states the patient required inpatient management for an ovarian mass which could not be safely managed at a lower level of care. No reason is given why this could not be safely managed at a lower level of care which is exactly what was done with this patient being discharged and scheduled for an elective surgical procedure. The agent also cites concerns of torsion, and requiring optimization for emergent surgery. If there were concerns of torsion, the patient would have required emergent surgery that evening and certainly not sent home with follow-up in one week. The surgery was never considered emergent. Finally, General Pediatric Admission criteria are not the most appropriate. The more appropriate Milliman Guideline is for Laparoscopic Gynecologic Surgery which considers laparoscopic surgery for excision of adnexal mass or ovarian disease (e.g., cyst) requiring removal as ambulatory.