Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gynecological - Laparoscopic Hysterectomy.
Treatment:  Inpatient stay.

The health plan denied the inpatient stay as not medically necessary.  The reviewer has upheld in whole the health plan denial.

This patient presented for a scheduled total laparoscopic hysterectomy, bilateral salpingectomy, and cystography for history of abnormal uterine bleeding that was ongoing for the past 12 years.  Patient reported that menorrhagia was present, and the pain had worsened as the years went on, and she required adult diapers due to the amount of bleeding.  She had an obstetric history noted for 1 prior cesarean 11 years ago.  She had breast surgery 7 due to breast reduction and postoperative infections requiring bilateral mastectomy and implants.  The patient also had undergone prior abdominoplasty.  The patient's allergies include penicillin and latex. 

The patient underwent a total laparoscopic hysterectomy, bilateral salpingectomy, dilation and curettage, frozen section, and cystoscopy.  The operative findings noted an enlarged fibroid uterus with dense lower uterine segment adhesions and bladder adhesions with omental adhesions.  The case was extremely difficult, due to the patient's prior abdominoplasty and previous abdominal surgeries.  The dissection of the adhesions and bladder flap lasted approximately 3 hours.

Postoperative day #1, the patient was reevaluated due to itching and redness, as well as tightness in her arms.  The patient reported that her arms were the worst, and they were swollen and red and tight.  The patient was given Benadryl, Solumedrol, and Pepcid IV and denied any shortness of breath, headache, dizziness, nausea or vomiting, or chest pain.  There was a likely allergic reaction secondary to latex in the operating room that may have involved exposure based upon her evaluation.  The patient was monitored overnight and was placed on Benadryl 25 mg (milligrams) twice daily and a Solu-Medrol taper.  She was also on Pepcid twice daily.  On the following day, the patient was much improved.  She reported flushing and warmth had improved.  She denied chest pain, shortness of breath, nausea and vomiting, or other complaints. 

There would be no medical necessity for acute inpatient level of care for a postoperative stay.  The patient underwent an uncomplicated procedure.  She was noted to have a mild skin reaction after the surgery that was consistent with allergy.  The source of allergy was uncertain, but there was no anaphylaxis or systemic reaction.  There was no acute hemorrhage or complication of surgery.  There was no evidence of cancer or staging.  The procedure in this case would be performed at a lower level of care as well as the monitoring and observation of the patient postoperatively would be performed at a lower level of care.

The American College of Obstetrics and Gynecology recommends implementation of Enhanced Recovery After Surgery (ERAS) pathways.  The basic principles of ERAS include attention to the following: preoperative counseling and nutritional strategies, including avoidance of prolonged perioperative fasting; perioperative considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis.  Benefits of ERAS pathways include shorter length of stay, decreased postoperative pain, and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction.  Implementation of ERAS protocols has not been shown to increase readmission, mortality, or reoperation rates.

In this case, the minimal invasive approach to surgery and normal recovery would be anticipated to result in lower level of care.