Appeal type: Medical necessity
Decision: Upheld

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

The patient is a para (P)1 female who presented for a plan of abdominal myomectomy in the setting of symptomatic fibroids who reported feeling well with no complaints. She was noted to have 1 prior term spontaneous vaginal delivery and 1 prior dilation and curettage. Past medical history was normal. Her past surgical history was noted for dilation and curettage. Her medications were negative. She had no known drug allergies. The patient did carry a diagnosis of symptomatic fibroids. She was on ferrous sulfate 325 daily and vitamin C as an outpatient.

Operative findings noted an enlarged uterus with multiple myomas, and the tubes and ovaries were normal. The patient had an uncomplicated procedure completed with the largest fibroid being 5 centimeter (cm) in the posterior aspect of the uterus as well as a 4 cm intramural fibroid and 3 cm submucous fibroid. These were removed without complications. The patient was taken to the post-anesthesia care unit (PACU) in stable condition following the procedure completion. She had no complications of anesthesia.
Following the procedure, the patient was noted to be alert and oriented and doing well. She was encouraged to ambulate and use her incentive spirometer. She reported progress was well overnight with pain controlled and she was passing flatus. Urine output was adequate and was one episode of asymptomatic hypertension, but vitals were otherwise normal. The patient was to have a morning complete blood count and to be advanced on her diet. She was encouraged to ambulate for possible discharge was planned on this date. The patient's vital signs remained stable, and she was noted to have a hemoglobin of 9.2 and hematocrit 29.9% with normal platelets of 233. The patient was doing well and was passing flatus and had had a bowel movement. She was tolerating a regular diet was planned for discharge at that time. Her vital signs remained stable on exam noted a well-healing incision. She was discharged to home with follow-up in office in 2 weeks. The patient was well recovered at that time. The subject under review is the medical necessity for the inpatient stay.

The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient who was admitted for a planned myomectomy. The Milliman Care Guidelines (MCG) Guideline entitled "Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy" were reviewed in concert with the medical records in this case. The surgical procedure was noted to be a myomectomy completed by laparotomy (Pfannenstiel incision) under general anesthesia. The surgery was uncomplicated. However, the surgical time for completion of surgery was only 2 hours 21 minutes. Thus, the surgery was completed in minimal time. There was no excessive blood loss with an estimated blood loss of 200 mL. There was no damage to bowel, bladder, or other intra-abdominal structures. The determination of the length of the necessary stay is based upon the optimal recovery course. Based on review of the medical documentation and the MCG Guidelines, there was no medical necessity for acute inpatient admission as the patient had no evidence for care that required acute inpatient admission as outlined by the Guideline. The patient could have been managed at a lower level of care and met discharge criteria following the procedure.
Thus, there was no criteria met to suggest moving this patient into an extended stay for hospitalization from the operation. Thus, in conclusion this patient was found to have no medical necessity for acute inpatient hospitalization under the MCG Guidelines for the dates under review.