Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia Repair

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

According to the patient's medical record, this is a patient who presented for elective hernia repair. The brief operative note indicated open lysis of adhesions, laparoscopic assisted ventral hernia repair with mesh. Findings included a large midline incisional hernia with multiple loops of bowel, extensive lysis of abdominal adhesions (LOA), insertion of mesh flush to abdominal wall. A 10 x 15 centimeters (cm) parietex mesh was placed and the surgery was done via gel port/laparoscopically. The lysis of adhesions was done using open technique. 

The post-operative check indicated the patient was doing well. Pain was well controlled. The patient denied nausea and vomiting. The patient was tolerating water. The plan was Tylenol and Dilaudid as needed (prn) for pain as well as clear liquid diet.

A nursing note on the following day indicted the patient was doing well. The patient denied nausea or vomiting. The patient was ambulating independently in the room and voided freely into the urinal. A progress note later that day stated that pain was poorly controlled that morning due to issues with the medication administration record (MAR) after transfer from the post-anesthesia care unit (PACU). The pain was now better controlled. A small amount of flatus was noted. No bowel movement (BM) was noted. The patient was tolerating a clear liquid diet. The patient was ambulating and voiding.

The discharge summary indicated the post operative course was uncomplicated and that by day 2 the patient was passing flatus, had a BM, and was tolerating a diet. The patient's pain was well controlled and the patient was deemed stable for a safe discharge to home. The patient was discharged.

The insurer has denied coverage for the full hospital admission as not medically necessary. In a Final Adverse Determination letter, they noted that they are not changing their decision. The insurer noted that the doctor wanted a full hospital admission after the hernia surgery. The plan considers a full hospital admission medically necessary when more surgery is needed or there are severe problems. 

The patient's surgeon is appealing. In an appeal letter, the surgeon stated that the patient was initially scheduled as laparoscopic and ambulatory. Unfortunately during the procedure they found dense adhesions and needed to convert to open surgery, do extensive lysis of adhesions and then repair the hernia with an inlay 10 x 15 cm composite parietex mesh. These operations are associated with significant pain when performed laparoscopically and when done open there are greater pain issues requiring parenteral pain medication plus the addition of the ileus associated with open surgery requiring extensive lysis of adhesions. It is clear that discharging a patient after an extensive nearly 5 hours in duration open surgery on the day of surgery would have been reckless and dangerous.

Based upon the records, the patient did not require inpatient hospital admission as they required observation care only. The provider kept the patient for pain control. The patient did not have evidence of significant ileus as they were tolerating clears as noted in the progress notes. The patient could have been managed in an observation status rather than acute inpatient admission. 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 appeared to be controlled adequately as noted in the progress notes. The patient was tolerating diet and was afebrile. 

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 full hospital admission is not substantiated.