Diagnosis: Vaginal Laceration.
Treatment: Inpatient Admission.

The insurer denied coverage for an inpatient admission.

The denial is upheld.

This case involves a child who sustained a vaginal laceration after landing on a metal slide. She was seen at the hospital on the date of her injury for laceration repair. Her vital signs were stable. Her preanesthetic evaluation noted the vaginal laceration where upon she was to undergo a vaginoscopy with cystoscopy and a laceration repair. Following surgery, the patient met criteria for discharge and was signed out by anesthesia.

An appeal was submitted stating that the patient was admitted for the management of a vaginal laceration and a full examination was limited by the patient's pain and anxiety. The report went on to state that the inpatient plan of care included preoperative optimization, intravenous hydration, and pain management. The surgery consisted of examination under anesthesia with a repair of the posterior vaginal laceration.

The Milliman Care Guidelines state that patients who have sustained a vaginal laceration can be cared for on an outpatient basis. The information provided for the review did not include any evidence of hemodynamic instability, excessive bleeding, or a significant injury that would require an acute level of care. Therefore, while it was noted that the patient was of a young age with reports that she was unable to be fully examined and required sedation, the extent of treatment to include examination under anesthesia with laceration repair could have been safely and effectively completed on an outpatient basis. The inpatient admission was not medically necessary.

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 inpatient hospital services is not substantiated.