Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld.

This patient is a female who was admitted for a uterine artery embolization procedure for complaints of constant abdominal cramping. She has a past medical history of uterine fibroids and seasonal allergies. She had a prior gynecology (GYN) history of an abnormal Pap smear with repeat that was normal. She reported heavy bleeding and chronic pelvic pain and was diagnosed with fibroids and adenomyosis. She reported taking ibuprofen as needed and nasal spray as needed for allergies. Her past surgical history included appendectomy, right elbow surgery, bilateral bunionectomy and a neuroma removal to both feet. The patient had no known drug allergies.
The patient underwent a bilateral uterine artery embolization without complications. There was no blood loss noted. At presentation post-operatively, the patient reported feeling nauseous and an 8 out of 10 abdominal pain. She denied headaches, dizziness, lightheadedness, shortness of breath, chest pain, tenderness, or vomiting episodes. The patient had normal vital signs with a blood pressure at 109/60, and a heart rate of 60. The patient had a pulse oxygenation at 97%. Her examination was appropriately tender with a Band-Aid on the right lower abdomen. Her lungs were clear, and the auscultation of the heart was a regular rate and rhythm.
She was admitted for a hydromorphone intravenous (IV) patient-controlled analgesia (PCA) and IV acetaminophen as needed. She was counseled on the PCA and the side effects and she agreed with the plan of care. The patient on postoperative day #0 was recovering well. Her exam was normal, and the plan was to discontinue the Foley catheter the next day, and if she were stable, she would be able to go home at that time. She was on a regular diet and lactated Ringer's at 125 cubic centimeter (cc) per hour. The patient rated her pain at 0/10 and her vital signs remained stable. On the following day, the patient had a pain score of 0/10.  Her pain was controlled, and she was afebrile. She was discharged home on Oxycodone 5 milligrams (mg), Ibuprofen 800 milligrams (mg) and Levofloxacin 500 mg per day.
At issue is the inpatient stay for medical necessity.

The health plan's determination of medical necessity is upheld in whole.

The inpatient stay was not medically necessary for this patient.
In this case, the patient was admitted for an interventional uterine artery embolization for the treatment of her fibroids. The patient had been symptomatic with urinary retention, pelvic pain, and bloating. This was an uncomplicated procedure. The patient was given sedation and had stable vital signs throughout and had no complications of the procedure. The patient, upon awakening, was noted to have cramping pain and was admitted for PCA pain control. She had no nausea, vomiting, limitations of oral intake or other complications requiring an inpatient level of care. The patient had excellent pain control.
In this case, the patient had no nausea or vomiting, normal intake, normal temperature, a normal wound, no infection or blood loss, and a normal abdominal status. The patient was able to tolerate oral intake and to be treated with oral pain medication. Generally, this procedure, with no complications as in this case, does not require an inpatient level of care per the generally accepted standards of care.
Therefore, the inpatient stay was not medically necessary.