Diagnosis: pelvic pain
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a female with pelvic pain. She presented to the emergency department with chest pain, breast heaviness and generalized abdominal pain. She also had nausea and vomiting. On exam, she had a vaginal discharge and voluntary guarding with right lower quadrant tenderness. Her vital signs were not contributory. A computed tomography (CT) scan showed a right ovary with multiple cysts. Pelvic ultrasound showed multiple cysts. She was empirically treated for pelvic inflammatory disorder with intravenous antibiotics and pain control.

Inpatient hospital stay is not medically necessary for this patient.
There are clear criteria for inpatient hospital admission with PID (pelvic inflammatory disease). They include surgical emergencies when appendicitis cannot be excluded, tubo-ovarian abscess, pregnancy, severe illness with nausea, vomiting and high fever of 101oF, unable to tolerate oral regimen, and no clinical response to oral antibiotics. The patient in this case did not have documentation of this and therefore, inpatient admission was not medically necessary. The patient could have been provided oral antibiotics for home use and follow up in the clinic for evaluation of treatment at a lower level of care.