Diagnosis: Ovarian Cyst
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.


The patient presented to the emergency department with complaints of right pelvic pain with nausea and vomiting. She had a history of diabetes and anemia. Her blood pressure was elevated but stable and her lab results showed a slightly elevated white blood cell count of 13.16. A pelvic ultrasound showed a 3.6 centimeters (cm) right ovarian cyst. A computed tomography (CT) scan showed a right ovarian cyst. She was admitted as an inpatient for the ovarian cyst and she had a laparoscopic ovarian cystectomy. After surgery she was doing well and was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital stay is not medically necessary for this patient.

The patient did not need medical inpatient monitoring and could have been monitored under outpatient or extended monitoring. She had no hemodynamic instability and the vital signs were normal. She had no hemorrhage. She had no pulmonary, renal or hepatic dysfunction. The procedure is an outpatient operation without the need for inpatient monitoring. In addition, there were no operative complications such as an infection, hemorrhage, nor pulmonary concerns. She tolerated anesthesia well without complications. She could have had the procedure and then been discharged from the post-anesthesia care unit (PACU) without the need for inpatient admission.