Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine perforation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient presented for a laparoscopy to remove an intrauterine device (IUD) from the abdomen after a uterine perforation. The IUD was not immediately found laparoscopically, and an unexpected ovarian cyst was encountered. The procedure was converted to an exploratory laparotomy. The procedure was complicated by bleeding from the left broad ligament and need for omentectomy. A gynecologic oncology consult was required to complete the extensive procedure. She was admitted to the hospital on the day of the procedure. At issue is the medical necessity of an inpatient stay.

The inpatient stay for this patient who underwent a diagnostic laparoscopy, hysteroscopy, exploratory laparotomy, ovarian cystectomy, omentectomy, and exploration of the retroperitoneum is medically necessary. This is a major surgical procedure. The patient requires parenteral pain medication usually for at least 24 hours, along with foley catheter drainage usually until the morning after surgery (with subsequent observation for proper voiding after that). Although early feeding is the contemporary routine, most patients are not actually tolerating any kind of diet for 12-24 hours. Recovery is usually 4 weeks after the surgery. The potential for complications, including bleeding, infection, bladder issues, and ileus, is robust in the first 24-48 hours after surgery so it is not safe to discharge these patients any sooner than that. The single night in the hospital in this case shows an aggressive timeline but should not diminish the need for an inpatient level of care for laparotomy patients. 
Studies show the average stay after abdominal myomectomy (a similar procedure) is 2.7 days. Other gynecologic laparotomy procedures show similar length of stay metrics. This procedure was extensive, lasting over 4 hours, and involved dissection not only in the abdomen but also in the retroperitoneum. Bleeding was encountered from several different sites. In the context of gynecologic procedures, this case represents a very significant and risky surgery. The level of care required is very high - intravenous (IV) hydration, parenteral analgesics, indwelling foley bladder drainage, and a high level of nursing assistance since the patient may not be ambulatory for 24 hours or more. Additionally, a high level of monitoring including vital signs, urine output, and usually postoperative laboratories, is required to assess for the many possible complications after such a major surgery. Unlike laparoscopy where the incisions themselves are small and contribute little to the patient's pain level, the large incision in a laparotomy generates a massive inflammatory response and imposes major restrictions on the patient. The postoperative care for this patient required an inpatient stay. Outpatient exploratory laparotomy does not exist and it is not prudent to consider such a major procedure to be followed by discharge in less than 24 hours. Laparoscopy, on the other hand, is routinely utilized as an outpatient procedure. The two approaches are vastly different in terms of the needs of the patient afterward, and therefore the lengths of stay are not comparable. Inpatient management was reasonable and expected after the procedure reported in this case.