Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the ED (emergency department) with a chief complaint of a one day history of moderate progressive abdominal pain following intercourse. Imaging demonstrates significant large volume hemoperitoneum on TVUS (Transvaginal Ultrasound). The plan was to admit the patient for observation with serial hematocrit measurements.

Because of persistent pain and drop in hematocrit, a diagnostic laparoscopy with evacuation of hemoperitoneum for ruptured hemorrhagic cyst was performed the day after admission. This was without complications. The patient was discharged home later that day.

No, the Inpatient Admission was not medically necessary.

This patient presented with abdominal pain. She was diagnosed with a ruptured bleeding ovarian cyst. The patient was stable based on her vital signs. There were two options to manage her: 1) Take her to the operating room or 2) Observe her for improvement or worsening.

The providers decided to observe her. Observation does not require admission. The patient could have been observed at a lower level of care, and when the provider felt that surgical intervention was necessary, she could have been taken to the operating room. Note that a diagnostic laparoscopy is an ambulatory procedure and does not require admission.

This patient underwent a laparoscopy. A laparoscopy is an ambulatory procedure.

According to MCG (Milliman Care Guidelines), Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for:
Older patients (> 65), Conversion to abdominal procedures, Surgical complications, Comorbidities.

This patient did not meet any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately.

In summary, this patient could have been observed for deterioration of her condition then had a laparoscopy. Neither observation nor laparoscopy require admission.

Based on the above, the inpatient admission was not medically necessary.