Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Inguinal Hernia

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

According to the patient's medical record, this is a patient with a history of recreational drug use disorder, paranoia, and right inguinal hernia. He was admitted to the surgical floor for a right inguinal hernia repair.  He was transferred from one hospital unit to another separate unit. As per the discharge summary his admission condition was stable. He had a computed tomography (CT) of the abdomen which showed a long tubular filling defect within proximal to mid small bowel associated with a transient intussusception and a large, small bowel containing right inguinal hernia. There was no evidence of a high-grade obstruction as contrast did traverse this region into the colon. The patient was transferred from the psych floor to surgery. He was admitted for management of reducible inguinal hernia. The patient was afebrile with stable vital signs. He had a right sided inguinal hernia that was reducible and nontender. As per the assessment and plan, the patient was admitted for management of the reducible right inguinal hernia. The patient underwent a preoperative evaluation for a hernia repair. He denied any pain or discomfort.

The patient underwent a right inguinal hernia repair with plug and mesh with no complications, under general anesthesia. The patient experienced urinary retention post-surgery and was straight catheterized, a foley was placed and the patient stated he wanted to be discharged with leg bag with outpatient follow up.  The patient was seen by psych for a safe discharge and was found not to have suicidal thoughts and the patient was psychiatrically cleared for medical disposition as there was no acute psychiatric intervention/ hospitalization warranted at this time.  He was discharged to home.

Based upon the records provided, the patient did not require inpatient hospital admission but rather 23 hour observation with the workup being done pre-op as an outpatient. He was transferred from the psychiatric unit to have his hernia repaired. This was not an incarcerated hernia as noted in the notes where it was described as reducible. It was also non tender. He was transferred and did not have the surgery as a planned procedure. His workup should have been done either while he was an inpatient at the psych unit or done as an outpatient as he did not need to have them done as an inpatient as it appeared to be an elective repair. Hernia repair could have been done in an observation/ ambulatory setting without inpatient admission.

To summarize the denial for coverage for the inpatient stay is upheld; the inpatient admission was not medically necessary as the patient could have been treated with a 23 hour observation/ambulatory status.  

The health care plan did act reasonably and with sound medical judgment.  This patient did not require acute inpatient admission and denial is upheld. All of his workup including clearance by hematology should have been done preop in the psych unit or as an outpatient. In fact, he was cleared the day that they saw him for surgery.  

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.