Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventral hernia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with BMI (body mass index) of 38.7. She presented to the hospital ED (emergency department) with complaints related to a ventral hernia. The patient's vital signs were normal at the time of ED (emergency department) presentation. The ED (emergency department) provider notes describe a diffusely tender abdomen. The WBC (white blood cell) count was elevated at 14.8 K (thousand). CT (computed tomography) scan showed a ventral hernia containing transverse colon with proximal bowel obstruction. Comorbid health conditions included hypertension and GERD (gastroesophageal reflux disease). The records indicate that the patient underwent laparoscopic ventral hernia repair with 15-cm (centimeter) mesh. The anesthetic record documents that the operation required 1 hour and 6 minutes to complete. The operative dictation describes performance of a laparoscopic robotic assisted ventral hernia repair with placement of mesh. The hernia defect was closed primarily with suture and reinforced with 9-cm (centimeter) mesh. The patient remained hemodynamically stable with normal vital signs following surgery. On 
post-operative day #(number) 1 she had normal vital signs and pain was well controlled. She was passing flatus. The diet was advanced. The discharge summary is dated on post-operative day #2 and notes that the operative and postoperative course were uncomplicated, and she was cleared for discharge. A discharge note dated the same day notes that the patient was discharging home with self-care. The submitted documentation references MCG (Milliman Care Guidelines) Hernia Repair (Non-Hiatal) 25th edition. The health plan rationale for denial is that the care provided could have been rendered in the observation setting as 
there was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care. The denial is being appealed.

The inpatient level of care was not required or medically necessary.

This patient had an incarcerated abdominal wall ventral hernia. The patient presented to the hospital due to obstructive symptoms related to the ventral hernia. She was hemodynamically stable at the time of presentation. The operation to repair the ventral hernia was performed the next day without complication. The submitted records document clinical stability in the perioperative period, and that the patient met criteria for discharge from the hospital following a period of recovery on day #4. Per the submitted MCG (Milliman Care Guidelines), the goal level of care is ambulatory. Extended 
stay or inpatient stay may be needed for emergent surgery, significant peritoneal adhesions complicating surgery, surgical complications, an obturator hernia, open repair of a large, recurrent or incarcerated incisional hernia, parastomal hernia, postoperative ileus, morbid obesity with BMI (body mass index) > 40, or active comorbidities. In this case there is no documentation to support that these criteria were met to warrant an inpatient level of care. The operation was completed without complication, and the patient responded promptly and favorably to the therapy provided. She was stable for discharge from the 
hospital on the second post-surgical day. The care during this time could have been rendered with a lower level of care such as observation status.