Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Paraesophageal hernia.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.
 
According to the documentation submitted, this is an adult with a history of diabetes mellitus, bladder cancer, gastroesophageal reflux disease (GERD) and paraesophageal hernia. The patient presented for elective admission to ambulatory surgery for a confirmed paraesophageal hernia repair. The plan was for elective procedure of laparoscopic paraesophageal hernia repair. As per the history and physical, the patient reported a history of GERD for 3 years and had recently experienced early satiety, chest pressure, and inability to sleep due to esophagitis. The patient was an American Society of Anesthesiologists (ASA) III. The patient underwent laparoscopic repair of hernia. The patient experienced intraoperative oliguria requiring an indwelling urinary catheter for monitoring. The patient received 3600 cubic centimeters (cc) of fluid, and the patient's urine output was only 110 milliliters (ml). There was associated hyperkalemia, which required medication to treat and cardiac monitoring. The attending physician noted that there were associated elevation hepatic enzymes. The patient's postoperative potassium level was 6.0. The next day, the patient was hemodynamically stable and was transferred to the surgical floor for continued management. An esophagram was scheduled for assessment. The patient's potassium was 4.5 and creatinine was 1.2. A chest x-ray showed decrease in subcutaneous emphysema. A progress note indicated the patient had appropriate urine output and was stable. On post-op day 2, the patient remained hemodynamically stable, and an esophagram showed no hiatal or paraesophageal hernia. The patient had an episode of hypertension in the night but was otherwise stable. The patient was discharged on a full liquid diet.

Although the operative status criteria are Ambulatory, as per Milliman Care Guidelines (MCG), MCG also noted qualifications to this. This is based upon the fact that the surgery was nearly 8 hours long, and the patient had decreased urine output during surgery, as well as hyperkalemia post-surgery with elevated transaminases. 

Milliman Care Guidelines 27th edition Ambulatory Surgery Exception criteria GRG:CG-AEC (ISC GRG) notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following:  1) Inpatient care needed for clinically significant preoperative disease or condition; 2) Complex surgical approach or situation anticipated; 3) Procedure is not low risk and patient at high anesthetic risk; 4) Presence of drug-related risk; 5) Inadequate outpatient care situation; or 6) Postoperative event, condition, or finding that warrants inpatient stay. 

The patient should not have been treated as an outpatient/observation status but rather inpatient given the length of the surgical operation and the complications that occurred during surgery. The criteria utilized by the reviewer include Milliman Care Guidelines (MCG) guidelines and the reviewer's experience. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.