Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leiomyoma
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The denial is upheld.

The patient is a gravida (G) 1 para (P) 0 abortion (A) 1 female who presented with a lower, uterine segment leiomyoma found initially on dilation and curettage (D&C), who was planned for abdominal myomectomy given this fibroid. The patient had been confirmed by pelvic magnetic resonance imaging (MRI) to have a 16 centimeter (cm) fibroid at the level of the fundus. The patient was noted to have morbid obesity with a body mass index of 49 kilograms per square meter (kg/m2). The patient was admitted for abdominal myomectomy. The patient's prior obstetric history was noted for a single spontaneous miscarriage that had required D&C. Per the history and physical, the patient's chief complaint was infertility. She had a prior history of carpel tunnel surgery and tonsillectomy. She had been on medications for in vitro fertilization (IVF). Her medications included a prenatal vitamin and iron supplement. She had no allergies. She was admitted to the gynecological (GYN) service for plan of surgery.

The patient underwent abdominal myomectomy and was noted to have a 16-17 cm subserosal fundal fibroid and a sub centimeter fibroid in the left uterine body. The patient had an estimated blood loss of 1600 milliliter (mL) during surgery. Vasopressin was used to control blood flow to the fibroid in concert with removal. The incision site of the uterus was closed in multiple layers. There were no other complications of surgery.

The patient was ambulating without difficulty. She had no lightheadedness, dizziness, palpitations, or chest pain. Her vital signs were stable with a heart rate of 84 and blood pressure of 124/64. Her examination was noted to be normal. The patient was clinically doing well and had completed a blood transfusion with an appropriate trend in her complete blood count. She was given one unit of packed red blood cells again and was to get a computed tomography (CT) angiogram to evaluate for any evidence of pulmonary pathology.

The subject under review is the medical necessity for the full hospital admission.

The full inpatient admission was not medically necessary for this patient who was admitted for a planned laparotomy for uterine myomectomy for the indication of infertility. The Milliman Care Guidelines (MCG) title "Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy" was reviewed in concert with the medical records in this case. The surgical procedure was noted to be a myomectomy completed by laparotomy (Pfannenstiel incision) under general anesthesia. The surgery was uncomplicated, but was noted for a total blood loss of 1600 mL without adverse hemodynamic instability. The surgery was completed in minimal time. The patient was offered and given a 2 unit blood transfusion followed by a third unit. There was no damage to bowel, bladder, or other intra-abdominal structures. The goal length of stay for this procedure based upon the MCG is Ambulatory or 2 days postoperative. The determination of the length of the necessary stay is based upon the optimal recovery course. The patient was noted to meet all aspects of care required for discharge from an ambulatory stay on the date of admission based upon the documentation reviewed which included all of the components of care. The patient could have been managed at a lower level of care.