Diagnosis: uterine fibroid embolization

Treatment: inpatient stay

The insurer is denied coverage for inpatient stay.

The denial is overturned.

This female patient has a history of anemia, human papilloma virus infection, hypertension, pneumonia, sexual dysfunction, uterine leiomyoma, menorrhagia.

This case involves a female who presented to the emergency department. The submitted documentation indicated per history and physical she presented with symptomatic uterine fibroids. The documentation indicated on physical exam her blood pressure was 122/82 with a pulse of 80 beats per minute and respirations 18. Oxygen saturation was 92%. The laboratory studies previously referenced were showing hemoglobin at 8.0. The documentation detailed she was recommended to undergo uterine fibroid embolization. She was admitted and did undergo embolization. She continued with observation. The documentation indicated postoperatively there was no bleeding or swelling at the procedure site. It was recommended she continue treatment and be discharged following day. The documentation detailed there was no documented adverse events and therefore, she was discharged the following day with instruction to follow-up.

The inpatient stay was medically necessary for the patient to be observed following uterine artery embolization. These patients should be observed for development of acute arterial access complications and management of postoperative pain, which usually requires intravenous (IV) pain medications and patient-controlled analgesia.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for inpatient stay is overturned. The medical necessity is substantiated.