Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibroids. 
Treatment: Inpatient Stay. 
The insurer denied: Inpatient Stay. 
The denial is Upheld. 

This patient is a female who presented with a chief complaint of fibroids associated with intermittent abdominal pain. The patient reported heavy menses and had fibroids removed before. She denied any chest pain, shortness of breath, fever, coughing or other complaints. The patient was noted have a past medical history of arthritis, cerebral palsy, hypertension, thyroid disease, and vitamin D deficiency. The patient has past surgical history that included myomectomy and hysterectomy, supracervical. The patient's social history was noted to be positive for smoking. She currently used marijuana. The patient had no allergies. Her current medications included Tylenol, atenolol, vitamin D, Voltaren, gabapentin, methimazole, and blood pressure monitoring. 

The patient was noted to be able to undergo surgery with general anesthesia with mild to moderate risk based upon her thyroid presentation. Patient was planned for supracervical hysterectomy for the indication of intramural, submucous and subserosal leiomyomas of the uterus. The patient had no complications of anesthesia. The operative note documented a preop diagnosis of intramural, submucous and subserosal leiomyomas of the uterus. The procedure included a supracervical hysterectomy. The patient was counseled on the plan of procedure. Patient was noted to have an 18 week size uterus with a large fundal myoma. The adnexa were noted to be normal. 

On postoperative day #1, the patient was status post exploratory laparotomy with supracervical hysterectomy. She had no complaints except incisional tenderness. The dressing was removed, and the wound was clean and well-healing. There was no drainage or induration. The patient's exam noted a surgical scar to be present with bowel sounds normal and absent distention. The abdomen was soft with no masses. There was no abdominal tenderness and there was no guarding or rebound. The wound was clean with no drainage, erythema or induration. Vital signs remained stable, and the patient was afebrile. The patient's hemoglobin and hematocrit remained stable postop. There was no ongoing bleeding. There was no concern for infection. Pathology documented a uterus specimen that had a leiomyoma 11 centimeters (cm) in greatest dimension. The weight was 183 grams and measured 10 x 5.5 x 5 cm. There was also an 11 cm fibroid present on the uterus. The patient was discharged to home with outpatient follow-up scheduled. 

The health plan's determination is upheld. 

Based upon a review of the medical records and the procedures and course of care, there would be no medical necessity for inpatient stay for a postoperative stay after supracervical hysterectomy. In this case, the patient underwent an uncomplicated supracervical hysterectomy. She was noted to have no complications of surgery or anesthesia and very little blood loss based upon post-op complete blood count. The patient remained with stable and normal vitals and pain was controlled. The total blood loss was minimal and there was no acute hemorrhage or complication of surgery. There was no evidence of cancer or staging. The patient recovered without complications and had a normal course of care. Given the postoperative recovery, the monitoring and observation would be performed at a lower level of care and would not have required an acute inpatient level of care.