Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventral hernia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

According to the patient's medical record, the patient presented for elective hernia repair. The patient's past medical history (PMHX) includes cardiac ablation, toe amputation, colon resection, and diabetes. The patient's Eliquis was held for 3 days prior to surgery. Preoperative creatinine was 1.34. The patient's electrocardiogram (EKG) showed atrial fibrillation.

As per the brief operative note, the patient underwent laparoscopic robotic assisted ventral incisional hernia repair with mesh and open subxiphoid incisional hernia repair with mesh. Surgery was uneventful.

Based upon the records provided, the patient did not require inpatient hospital admission as the patient should have been managed in observation care only. The provider kept the patient in the hospital because of the slightly elevated potassium which the patient has had in the past as well as the slightly elevated creatinine which the patient also had in the past. These only needed to be monitored. The patient was also tolerating diet and was afebrile as well as symptomatic. Thus, the reviewer does not see why the patient needed an acute inpatient stay but rather a 24-48 hour observation stay.  

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Hernia Repair (Non-Hiatal) ORG: S-1305 (ISC), the operative status criteria is ambulatory.  MCG also noted extended inpatient care may be warranted in certain situations as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days). 

In addition, MCG health General Recovery Guidelines 27th edition General Surgery or Procedure GRG: SG-GS (ISC GRG), notes that Operative Status Criteria is ambulatory for many procedures. In this case the patient should have been managed as an outpatient with a 24-48 hour observation without acute inpatient hospitalization as this surgery is an ambulatory status as the patient did not have any factor to necessitate inpatient status. 

Finally, MCG Health noted in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: Hemodynamic instability; Acute peripheral ischemia (e.g. pulseless, cool, mottled, or cyanotic extremity; Cardiac arrhythmias of immediate concern;  Severe respiratory findings; Severe airflow or ventilation abnormalities; Anasarca; Neurologic abnormalities; Altered mental status that is severe or persistent: physiologic disorder(e.g., acute acidosis, thyroid storm, adrenal crisis) that is severe or persists despite observation care, suspicion for or diagnosis of abdominal catastrophe (e.g. Peritoneal signs, Temperature less than 95 degrees F (fahrenheit) ( (35 degrees C) (rectal); Severe electrolyte abnormalities requiring inpatient care;  Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; Adverse drug or systemic toxin reaction that is severe or persists despite observation care (e.g., serotonin syndrome, neuroleptic malignant syndrome, cholinergic syndrome, anticholinergic syndrome); Severe pain requiring acute inpatient management;  Inpatient monitoring  needed; Treatment requiring inpatient care; Emergency procedures needed.  Based upon these guidelines this patient should have been observed rather than placed in an acute admission as the patient did not have any indication as noted above for inpatient stay. The patient had chronic atrial fibrillation, and this was not acute. Thus, the patient did not need an acute inpatient stay of 2 days for this. At best the patient only needed to be observed.

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 the inpatient admission is not substantiated.