Diagnosis: Ovarian torsion
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient presented with severe abdominal pain, and findings suggestive of torsion. She underwent an uncomplicated laparoscopic left oophorectomy.

According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for: Older patients (>[greater then] 65), Conversion to abdominal procedures, Surgical complications, or Comorbidities. The patient did not meet any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately. Her incisional pain was minimal.

The laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for hospital admission is not substantiated.