Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a gravida (G)0 para (P)0 female who presented with sharp stabbing left lower quadrant pain that started around in the early morning. The pain was constant and have progressively worsened since that morning. The patient vomited  2 in the morning. She presented to the emergency department at early afternoon. Morphine was given 1.5 hour later and the patient denied any urinary symptoms. The patient was sexually active with 1 partner with her last sexual activity around a week ago. There were no other complaints. There was no significant past medical or surgical history. The patient denied any prior obstetric history. The gynecological (GYN) history is noted for an abnormal Pap smear last year with colposcopy performed that was normal. An ovarian cyst of 8 centimeter (cm) was visualized on ultrasound. The patient denied smoking or use illicit drugs. She drinks socially on weekends. The patient reported no known drug allergies in her meds include oral contraceptive pills.

The patient was taken to the operating room and underwent general anesthesia for a preoperative diagnosis of ovarian torsion and a postoperative diagnosis a portion of the left ovary and ovarian pedicle. The patient underwent a diagnostic laparoscopy and laparoscopic left ovarian cystectomy with a laparoscopic partial left salpingectomy. Operative findings included an anteverted uterus and left large adnexal mass on bimanual exam. A 12 x 8 cm left ovarian cyst, ovary and cyst were torsed around the pedicle 2 rotations. The ovary was detorsed and the cyst was removed. The ovary was noted to have good vascular supply and concern for compromising the vasculature of the left fallopian tube was noted after separation from the ovarian cyst. Given this concern a partial left salpingectomy was performed. The patient had an estimated blood loss of 50 milliliters (mL) with 800 cubic centimeters (cc) of intravenous (IV) crystalloid and urine output 225 mL. There were no complications of surgery noted. The total time of surgery was 1 hour 14 minutes. Anesthesia records noted an uncomplicated procedure as well as the operative report. Vital signs remained stable throughout the procedure. The patient was discharged to home in stable condition with follow-up scheduled in the outpatient setting. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld. 

The inpatient stay was not medically necessary for this patient given the diagnosis of stable abdominal pain with possible ovarian torsion with stable vital signs. The American College of Obstetrics and Gynecology (ACOG) recommend that the care for laparoscopic surgery for ovarian torsion does not require acute inpatient medical care. In this case, the patient met the ability to have pain controlled with oral medications, tolerate regular diet, and ambulate. She had no limitations to understanding post operative instructions. Thus, she was appropriate for treatment at a lower level of care status. Based upon a review of the medical records and the procedures and course of care, there would be no medical necessity for acute inpatient level of care for a postoperative stay after laparoscopic surgery for ovarian torsion without complications.