Diagnosis: Uterine Fibroids

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient is a female with a history of anemia and fibroids. She presented to the hospital for a scheduled laparoscopic hysterectomy to treat uterine fibroids and abnormal uterine bleeding (AUB). The patient underwent a laparoscopic supracervical hysterectomy, bilateral salpingectomy, and myomectomy. Estimated blood loss (EBL) was 800 milliliters (ml). Hematocrit (hct) level was low. The patient was admitted for postoperative care. She was kept on a regular diet. Heparin was given for deep vein thrombosis (DVT) prophylaxis. The patient was able to void and the Foley was removed. She was discharged after a period of hemodynamic stability.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.
Laparoscopic supracervical hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines, Inpatient and Surgical Care 24 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:

1) Surgical complications (bladder ureter or bowel injury or hemorrhage)
2) Conversion to abdominal hysterectomy
3) Complex surgery (staging of endometrial cancer)
4) Wound complications
5) Co-morbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post-operatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.
Please note that this patient had a supracervical hysterectomy. In other words the vagina was not entered and the procedure is much less invasive than a total hysterectomy. So the recovery period and complications should be much less than with a total hysterectomy.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is not considered medically necessary for this patient.

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.