Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incisional hernia
Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a female patient with a history of hysterectomy complicated by bleeding, requiring a midline laparotomy. The patient presented to the Emergency Department (ED) with a complaint of excruciating pain in the suprapubic area for 5 days which was noted to be disabling as she could not move or walk. The patient's vital signs were stable and she was afebrile. As per the ED provider the patient had blood work and a computed tomography (CT) scan done recently at another ED and all were negative. On examination the patient had suprapubic tenderness. Her abdomen was soft and non-distended. As per the provider note, surgery saw the patient and found an incisional hernia with incarcerated fat. 

The patient was admitted to surgery with the plan for hernia repair. The patient underwent open repair of incisional hernia with ventralux mesh. As per the operative note, the CT of the abdomen showed a small incisional hernia in the suprapubic area that had pre-peritoneal fat that had herniated. The patient tolerated the procedure well without complication and was taken to the recovery room in good condition. The patient was admitted to the unit post-operatively. Her pain was well controlled. She was ambulating, passing flatus and having bowel movements. On day 2 of admission the patient was stable based upon cardiac status for discharge. She was discharged with outpatient follow up.

Based upon the records provided, the patient did not require inpatient hospital admission as the patient underwent an uneventful repair of incisional hernia with mesh which could have been done in an observation status and not an acute admission. The patient was cleared by cardiology. The surgery was uneventful, and she was discharged the following day when she could have been discharged following a 23 hour stay and not an acute inpatient admission.

According to MCG [Milliman Care Guidelines] Health Inpatient and Surgical Care 24th Edition Hernia Repair (Non-Hiatal) ORG: S-1305 (ISC), the operative status criteria is ambulatory for almost all patients undergoing inguinal, femoral, or umbilical hernia repair as they can be treated on an outpatient basis, as well as some patients undergoing ventral (primary and incisional) hernia repair. However inpatient may be warranted for emergent procedures for patients with very large ventral hernias, for patients with poorly controlled co morbidities that require inpatient-monitoring, for patients with morbid obesity, or if significant surgery beyond hernia repair is needed. Some patients undergoing repair of a recurrent ventral or incisional hernia, or open repair of an incisional or ventral hernia requiring mesh implantation may require inpatient care. In many ways this was not an emergency operation, but rather an elective repair of this hernia. The hernia therefore did not meet the criteria for inpatient admission. Thus, acute care admission was not warranted.

The health care plan did act reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.