Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

 
According to the patient's medical record, this patient had an exploratory laparotomy with lysis of adhesions and sigmoid resection for diverticular disease. Subsequently, the patient presented for incisional hernia repair. As per the paperwork the plan was for inpatient admission as noted by the documentation as per the order signed. The history and physical (H&P) on 8/10 indicated the patient had a new incisional hernia. The patient had prior colon surgery for a diverticular stricture. Since then, the patient has developed a bulge in the midline which was not particularly painful but was uncomfortable.  The patient had a prior robotic incisional hernia repair with mesh 3 x 30 centimeter (cm). The plan was for incisional hernia repair with mesh placement (sublay). 

The patient underwent an open incisional hernia repair for non-incarcerated incisional hernia. A 30 x 18 cm ventralight mesh was used. A Blake drain was placed over the mesh. The estimated blood loss (EBL) was minimal. It was noted the patient tolerated the procedure well.

The provider kept the patient in the hospital because of the drainage from the Blake drain-this is expected given that the drain was placed above the mesh which is porous. In addition, there was no need to wait for return of bowel function per se as the patient had a non-distended abdomen and it could take a day or two for bowel function to return. In addition, the pain was being controlled adequately and the transition could have occurred sooner to oral medication which probably would have led to faster recovery of bowel function. The patient was also tolerating diet and was afebrile. Thus, this stay could have been done as a 24-48 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). The patient did not have a post op complication; the patient did not have a wound infection; the patient was not bleeding, and the patient did have adequate pain control.

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 other 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 very specific reasons.  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.

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.