Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abnormal uterine bleeding with failed intrauterine pregnancy.
Treatment:  Inpatient Hospital.

The insurer denied the inpatient hospital stay.  The denial is upheld in whole.

This patient is a female who presented to the hospital emergency room (ER) with complaints of vaginal bleeding and cramping.  She reported she was supposed to have an abortion in two days and had a history of a fibroid uterus. She also reported vaginal pain.  She reported that her bleeding was moderate with spotting and clots intermittently.  There was pelvic pain and cramping.  She had had no previous history of miscarriage.  The patient was noted to have a normal examination.  The abdomen was noted to be flat.  The cervical exam noted cervical bleeding present in the vagina had blood in the vault.  The uterus was enlarged, fixed and tender.  The right adnexa were normal.  The patient had no cervical adenopathy present.  The remainder of the exam was normal.  The plan was made for gynecologic consultation given this presentation with laboratory testing.

The patient was seen by the GYN service and admitted to the hospital.  The patient was noted to have abnormal uterine bleeding with a failed intrauterine pregnancy and increased vaginal bleeding.  The patient's vital signs remained stable.  Her blood pressure was 110/71 with a heart rate of 67 and temperature of 98F.  The patient had a hemoglobin 7.2, which was stable from the prior assessment a week earlier at 7.4 g/dL.  The hematocrit was 25.7%, which was stable from an assessment the week prior at 27.1%.  Her white blood cell counts were normal.  Platelets were normal at 172.  The patient was planned for surgical management.  Type and cross for 2 units was completed.  A plan was made for Depo-Provera for contraception after the case.  The patient was consented for dilation and curettage (D&C).  Her diagnosis was failed pregnancy and vaginal bleeding.  The patient was noted on ultrasound to have an irregular gestational sac with a yolk sac and no fetal pole with a beta hCG of 16000.  The patient had been seen in family planning clinic where her options for felt pregnancy were discussed.  The patient had understood that she was not a candidate for medical management due to her anemia.  The patient denied dizziness, lightheadedness, weakness, nausea, vomiting, fever or chills.  She had a previous history of term spontaneous vaginal delivery on one prior occasion.  The patient's blood type was A+ and a basic metabolic panel was normal.  Repeat ultrasound was completed and again noted an irregular gestational sac with yolk sac with no fetal pole visualized.  The patient was counseled about having her surgery at that time.  The patient had an appointment for her dilation and curettage, and the patient was counseled on option of keeping that appointment with strict bleeding precautions versus adding her on for dilation and curettage on the current date.  The patient was also offered blood transfusion and declined blood transfusion at that time she was given strict bleeding precautions and strict return to the hospital precautions.  Ibuprofen 600 mg every 6 hours and Tylenol 650 every 6 hours for pain were recommended.  

The patient was taken to the operating room (OR) and underwent a dilation and curettage without complications.  She reported that her pain was cramping quality and moderate on postoperative evaluation.  She had no chest pain or shortness of breath.  There was no dizziness.  She had been voiding urine for total of 550 cc of output, which was adequate.  The patient's examination was benign, and there was spotting on the pad noted.  The patient was now postop and in stable status post suction dilation and curettage.  The patient had a repeat complete blood count and started a Methergine series to control any ongoing bleeding.  She was to be on Depo-Provera for birth control and have sequential compression devices placed to prevent venous thromboembolic disease.  The following day the patient was resting comfortably without complications. She had no fever, chills, nausea, or vomiting.  She had no other complaints.  There were no significant complications or problems.  The patient was to be discharged to home with follow-up at the outpatient office.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary for this patient.  The patient presented with an incomplete abortion (bleeding with a failed intrauterine pregnancy) that had been diagnosed prior.  She also was noted to have chronic anemia that had been stable, and her complete blood counts were stable.  She presented with onset of bleeding and cramping.  She was taken to the operating room after type and cross for 2 units of Packed red blood cells (PRBCs) and counseling and consent.  The patient had fibroids which made the D&C technically more difficult but still uncomplicated.  She had no febrile morbidity.  There was no excessive blood loss (400 cc reported), and her complete blood count remained stable.  She had no complications.  She was discharged to home in stable condition.  In this case, there is no evidence that this was anything more than an incomplete abortion that required dilation and curettage, which can be completed at a lower level of care status.  There was no tachycardia, sepsis, fever, or hemodynamic instability.  Thus, there would have been no indication for admission to acute inpatient level of care.