Diagnosis: Hemorrhagic ovarian corpus luteum.
Treatment: inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is a female who presented with abdominal pain of 2 days duration. Vitals were stable. The patient has a history of end stage renal disease status/post (s/p) failed renal transplant. Ultrasound on presentation showed a right ovarian hemorrhagic corpus luteum. The patient was admitted for observation and serial hematocrits and possible surgical intervention. The patient's pain improved. Her hematocrit was stable. The patient underwent 2 hour dialysis and was discharged home.

Most patients with ovarian cyst rupture have an uncomplicated course and are candidates for observation. Complicated patients (i.e., hemodynamic instability, large or ongoing blood loss, signs of an infection process, findings suggestive of malignancy) may require inpatient management and/or surgery.

Patients with hemodynamic instability require immediate surgical management. For most patients with a ruptured ovarian cyst who are hemodynamically stable but have significant hemoperitoneum or concern of ongoing blood loss, hospitalization with close observation. Close observation includes frequent vital signs, serial hemoglobin/hematocrit testing, fluid replacement, and repeat pelvic ultrasound, if needed. Surgery is required if ongoing hemorrhage needs to be controlled and/or if the patient's clinical condition is unstable.

This is a sick patient who presented with a very low hematocrit. Admission for close observation and possible surgical intervention was medically necessary.

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.