Diagnosis: Cervical dysplasia
Treatment is an inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld.

This is a patient who was s/p (status post) supracervical hysterectomy and bilateral salpingo-oophorectomy (BSO). She underwent a trachelectomy and repair of cystocele with suspension of the anterior vaginal wall. The patient was admitted after failing the voiding trial post-operatively; however, she was able to void over-night. The patient voided 200 cubic centimeters (cc) and 150 cc, and a bladder scan revealed a residual volume of 500 cc's. The patient was medically stable and discharged home with a foley catheter in place with a leg bag. The patient was advised to follow-up as an outpatient for foley removal.

A trachelectomy with an anterior repair is an outpatient procedure. Note that a vaginal hysterectomy which is a much more involved procedure is an outpatient procedure. The safety of this approach has been documented in multiple studies.
Admission is usually not necessary unless there is a possible complication such as: heavy bleeding, surgical complications (bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, wound complications or comorbidities.

This patient's procedure was uncomplicated. There was no evidence of any injury to other organs. A trachelectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. In other words, the patient could have been monitored overnight without the need for an admission and once the provider ascertained that the patient was stable, the patient could have been sent home with a foley catheter.
Based on the above, the inpatient admission was not medically necessary for this patient care and management.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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