Diagnosis: Uterine Leiomyomas.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is: Upheld.

In this case, the patient is a female who was admitted for plan of abdominal myomectomy due to leiomyomas of the uterus. The patient had general anesthesia without complications and had an estimated blood loss of 2200 milliliters (mL) during surgery. She was noted to have an 18 week sized uterus with 45 fibroids existed. There were three incisions made into the uterus with one entry into the endometrium. The right fallopian tube was oversewn due to bleeding. She had 4 units of blood given during the operation with one unit of Tranexamic acid (TXA) for hemorrhage. The patient also underwent an abdominoplasty procedure during the surgery. Vasopressin was used for control of uterine blood flow during the myomectomy. The patient had an additional dose of Ancef due to excessive bleeding during surgery. The patient was also noted to have hypertension.
In this case, the patient was admitted to the hospital post-op due to excessive surgical bleeding with myomectomy and abdominoplasty. Following surgery, vital signs were stable with afebrile status at 99.2 Fahrenheit (F) with blood pressure of 121/87 and hear rate of 74. She had a normal pulse ox of 100%. She had a respiratory rate of 18. Her hemoglobin was 7.8 after surgery and recovered to 13.3 with blood transfusion. Her hematocrit was 24.1 after surgery and recovered to 40.2%. Pain was managed on oral Motrin and oxycodone. She was on Amlodipine 5 milligrams (mg) per day for hypertension. She had good urine output and a Jackson-Pratt (JP) drain with 100 cubic centimeters (cc) fluid out. She was discharged to home with follow-up in the outpatient setting. Hemoglobin was 9.8 with hematocrit of 29.1%.
The subject under review is the medical necessity for inpatient hospital admission.

The health plan's determination is upheld.

Based upon a review of the medical records in this case, the inpatient hospital admission was not medically necessary. The care could have been provided safely and effectively at a lower level of care status. In this case, the patient was noted to have a myomectomy by abdominal incision with removal of 40 plus (+) myomas. She also underwent an abdominoplasty. This was completed subsequent to the myomectomy. Thus, the patient was noted to have 2200 mL of total blood loss and the patient also underwent abdominoplasty without complication after the blood loss from the myomectomy. The recovery was uncomplicated. Vitals following surgery were stable and the patient was afebrile. Thus, in conclusion this patient was found to have no medical necessity for acute inpatient hospitalization under the Milliman Care Guidelines (MCG) Care Guidelines for dates of stay in question.