Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Uterine Fibroids.
Treatment:  Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission.  The denial is upheld.

The patient is a gravida (G)2 para (P)2 female who presented for surgical management of uterine fibroids with plan of abdominal myomectomy. The patient denied fever, chills, headache, changes in vision, right upper quadrant pain, dizziness, chest pain, shortness of breath or calf tenderness. The patient's obstetric history is noted for 2 prior full-term deliveries by Cesarean. The patient also had a prior appendectomy and odontectomy. The patient's preoperative hemoglobin was 11.9 with hematocrit of 37% and platelets of 224. A basic metabolic panel was noted to be normal.

The patient was taken to the operating room where she underwent general anesthesia without complications. The patient was given 2 grams (g) of Ancef for preoperative infection prophylaxis. She was placed in dorsal supine position and underwent a Pfannenstiel skin incision for access to the abdomen. The patient had a total removal of 12 myomas that ranged in size from 3 centimeters (cm) to 1 centimeter (cm) and the endometrial cavity was entered during the procedure. There were normal ovaries and tubes. The estimated blood loss was 100 milliliters (mL). Urine output was 150 mL. The IV fluids were 1200 mL. There were no complications of surgery, and the patient tolerated the surgery without complications.

The patient was noted to have stable vital signs in the recovery room with the Foley draining yellow urine and sequential compression devices in place. The patient's center was afebrile at 98.8 with a heart rate of 59, blood pressure 110/73. The patient was moved to the floor for ongoing care after the procedure.

On postoperative day 2, the patient was seen and evaluated at bedside and stated that Tylenol was helping with pain, but the Naprosyn was not. The nausea and vomiting were improved, and the patient denied any emesis. She was tolerating clears and endorsed flatus. She had no bowel movement as of yet. She was not yet ambulating to the restroom. She had been voiding and using a bedpan. The patient was encouraged to ambulate with the aid of a nurse, and the patient confirmed that she would do this. The patient's vital signs were stable, she was afebrile. The abdomen was soft nontender and nondistended. Bowel sounds were hypoactive, and the incision was clean, dry and intact. The patient was status post abdominal myomectomy on postoperative day #2 and was ordered for Motrin and Tylenol for pain with a bowel regimen and encouraged ambulation. She was on a regular diet and planned for Methergine series. She was to be discharged home after she was ambulatory.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient. The Milliman Care Guidelines (MCG) Health Guideline entitled "Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy" (25th Edition) were 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 as was the anesthesia. Based on review of the medical documentation and the MCG Health Guidelines, there was no medical necessity for acute inpatient admission, as the patient had no evidence for care that required acute inpatient admission as outlined by the Guidelines. The patient could have been managed at a lower level of care.