Appeal type: Medical necessity
Decision: Upheld

Gynecological - Gynecological
Inpatient Hospital

This patient is a female who was admitted to the hospital for an elective procedure to remove an ovarian cyst that was present on the right ovary which was found on pelvic ultrasound. The patient was noted to have a history of hypertension that was diet controlled, asthma and morbid obesity. She denied abdominal pain. There was no chest pain or shortness of breath noted. The patient had a prior history of a diagnostic laparoscopy and a right ovarian cystectomy in mid 2019. There is a history of a mother with cancer and a father who had hypertension. The patient was noted to have a Pap smear that was up to date. She was a non-smoker. At presentation, her blood pressure was 159/86 with a heart rate of 84. Respiratory rate was 16. The patient was afebrile at 98.6. She had a height of 5 foot 4 inches. Her examination was noted to be normal and the abdomen was obese with positive bowel sounds. This was nontender and without masses. The pelvic exam was deferred.

The patient was taken to the operating room where she had a preoperative diagnosis of ovarian cyst and a postoperative diagnosis of the same. The patient underwent an uncomplicated laparoscopic ovarian cystectomy. At the time of operation, there was a large simple-appearing left ovarian cyst that was grossly normal. The uterus was also grossly normal and there was a normal right ovary. There was a normal-appearing liver and gallbladder. The patient had a specimen sent to pathology consisting of the ovarian cyst wall. Estimated blood loss was 50 milliliter (mL). The patient received 100 mL of intravenous (IV) infusion and 200 mL of urine output was present during the procedure. The patient was moved to the post-anesthesia care unit (PACU) in stable condition and was then moved to the hospital for her ongoing care. 

Anesthesia records noted the patient had an uncomplicated procedure. The patient had no complications of anesthesia. The patient was noted to have a normal postoperative hemoglobin and hematocrit at 10 and 33% respectively. Platelets were normal at 325. The patient was managed on ibuprofen and Tylenol for pain control. She was using albuterol as needed for shortness of breath. The patient had no acute events overnight following surgery there were no complaints. Pain was well-controlled on oral medications and she was ambulating and tolerating a regular diet. The patient was passing flatus. The patient was voiding spontaneously. She denied chest pain, shortness of breath, nausea or vomiting, fevers or chills. The patient stated she was ready to go home. Her vital signs remained stable with a blood pressure of 140/76, heart rate of 90. Her oxygen saturation was 97%. She had excellent urine output 1000 mL. The patient was discharged to home with well-healing incisions and no bleeding noted. She had follow-up scheduled in the outpatient setting.

The health plan's determination is upheld.

The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient who was admitted for a planned right laparoscopic cystectomy for an ovarian cyst. The Milliman Care Guidelines (MCG) entitled "Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy" were reviewed in concert with the medical records in this case. The surgical procedure was noted to be a laparoscopic ovarian cystectomy on the right ovary under general anesthesia. The surgery was uncomplicated, and the patient had no anesthesia complications. However, the surgical time for completion of surgery was 107 minutes (17:16 to 19:03PM). Thus, the surgery was completed in minimal time. There was no excessive blood loss with an estimated blood loss of 50 mL. There was no damage to bowel, bladder, or other intra-abdominal structures. The guideline requires the following: Procedure completed - This criteria is met, Hemodynamic stability - this was noted during and following the procedure and was documented to be present in the PACU. This criteria is met, No evidence of postoperative or surgical site infection - this was not present and this criteria is met, The wound was well healing (5 port sites), Pain absent or managed - pain was managed by oral medications in this patient and this criteria is met, Oral hydration, medications, and diet - this was met as the patient was on oral hydration, pain medications, and diet, Ambulatory - this patient was ambulatory and this criteria would be met, Discharge plans and education understood - this is met as there was normal mental status and counseling present. 

Based on review of the medical documentation and the MCG Care 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 Guideline. The patient could have been managed at a lower level of care and met discharge criteria following the procedure. The MCG Guideline allows for extension of care to inpatient for certain conditions as follows: Extended stay beyond goal length of stay may be needed for: Complex surgery (e.g., ovarian carcinoma debulking involving bowel resection, pelvic exenteration) - this was not present in this case. This was a straightforward ovarian cystectomy with a normal operative time. There was no concern for cancer.
Expect brief to moderate stay extension, Surgical complications (e.g., bladder, ureter, or bowel injury or bleeding) - these were not present, Comorbidities (e.g., peritonitis) - this was not present, Older patient. Patient 65 years or older may require longer acute hospital care. - this was not present. 

Thus, there was no criteria met to suggest moving this patient into an extended stay as inpatient level of care for hospitalization from the operation. Thus, in conclusion this patient was found to have no medical necessity for acute inpatient hospitalization.