Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibroid uterus
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is an adult female with heavy menses secondary to a fibroid uterus. She has had anemia requiring blood transfusions. She was diagnosed with a seizure disorder. She underwent elective open supracervical hysterectomy and right oophorectomy/salpingectomy, and lysis of adhesions. Estimated blood loss was 400 cubic centimeters (cc). The patient was given intravenous fluids, intravenous narcotics, intravenous anti-nausea medications, sequential compression devices, and a Foley catheter. On day #1, the patient had an acute seizure. This required intravenous anti-epileptic medications and close monitoring. She had a neurology consult and a head computed tomography was normal. The patient had lab work which revealed anemia with a hemoglobin of 8.1. Otherwise, labs were within normal range. The patient was continued on her lacosamide but had the amitriptyline stopped. She was cleared by neurology to follow up as an outpatient.

The inpatient stay was medically necessary.

In a review of the current literature summarized by Stovall and Mann, the average length of hospital stay after abdominal hysterectomy in the United States is three days. Routine postoperative care includes monitoring of a patient's hemodynamic and fluid status, pain control, and reintroducing normal diet and activity. Post-operative pain is managed initially with parenteral administration of analgesics. Patient-controlled anesthesia is an option. This is transitioned to the oral route when a patient can tolerate oral intake, usually on the first postoperative day. The bladder catheter can be removed during the first 24 hours postoperatively. A systematic review of randomized trials was conducted regarding use of urinary catheterization after urogenital surgery in adults. Fewer urinary tract infections resulted when a catheter was removed after one versus three days (RR 0.50, 95% CI 0.29-0.87). Also, decreased risk of recatheterization was associated with use of a postoperative catheter versus no catheter, as well as with a suprapubic catheter versus a urethral catheter. Postoperative colonic stasis after major abdominal surgery lasts approximately three days but does not typically require nasogastric decompression or preclude early feeding. Early feeding of a regular diet can stimulate the bowel and decrease the length of hospitalization, although emesis is common. Preventive measures are appropriate for patients at high risk of postoperative pulmonary complications. All patients are also encouraged to ambulate as soon as is feasible.  Discharge criteria following surgery vary depending on the surgical procedure performed. In general, the following are the standard recommendations that the patient must be meeting prior to discharge:
1) adequate pain control
2) stable vital signs
3) return of bladder and bowel function
4) adequate oral intake.

The patient had an open supracervical hysterectomy. This necessitated needing more than one night in the hospital to ensure that she could ambulate, void, have adequate pain control, and stable vital signs. This required an inpatient setting given the care would cross over 24 hours which is longer than the period of observation. This patient's post-operative course was then further complicated by seizure activity. This required acute intravenous medications and a computed tomography scan. The patient needed to be monitored more closely given this seizure activity. Once the patient was tolerating diet, ambulating, voiding, passing flatus, tolerable pain, and had no further seizure activity she was deemed stable for discharge. In summary, the patient's post-operative care did require an acute inpatient stay which is recommended by the literature.