Gynecological
Inpatient Hospital

The patient is a female, gravida 6 para 4, at 9 weeks gestational age in pregnancy, presented to the emergency room with right lower quadrant pain. She was found to have a large right ovarian cyst on imaging measuring over 6 centimeter (cm). A viable intrauterine pregnancy was confirmed on the ultrasound. Her history was remarkable for a history of surgery for ovarian cysts. She was admitted the night she presented, and then discharged the following day pain-free. She did not undergo surgery.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The health plan has acted reasonably. The brief time in the hospital did not require an inpatient level of care. This was time in the hospital to assess what clinical action should be taken (surgery or discharge). The patient underwent pain control measures, but otherwise no interventions other than assessment of the need for surgery. She was not receiving any significant interventions during that time. The progress notes demonstrate a resolution of pain overnight followed by no further need for analgesics. There is nothing to suggest there was ongoing concern for infection or other serious problem. She did not require transfusion, she was afebrile, and there was no pending clinical problem requiring the hospital.

Inpatient admission was not medically necessary for this patient. The patient presented with a very common complaint - ovarian cyst. Ovarian cysts are evaluated in the emergency room on a regular basis, usually with discharge once blood flow to the ovaries is documented on sonography (i.e. ruling out torsion). Professional guidelines recommend surgery for functional cysts only if they are 10 cm or above or associated with ovarian torsion. The providers in this case took a conservative approach in placing this patient in the hospital to assure surgery was not needed. Her pregnancy no doubt influenced that level of caution and is completely reasonable. However, the patient's pain resolved within hours of her placement on the floor. Her vital signs remained normal (for a pregnant patient) and her labs likewise were unremarkable for a pregnant patient (mild anemia and mild leukocytosis are normal in pregnancy). She did not require surgery, or other interventions that could not be provided in an emergency room setting, and so inpatient admission was not medically necessary.