Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inguinal and Umbilical hernia

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission.

The denial is upheld.

The patient is a male with a past medical history of hypertension, gastroesophageal reflux disease (GERD), and sleep apnea.  He presented to the hospital for a scheduled laparocopic right inguinal and umbilical hernia repair.  As per the History & Physical (H&P) the patient passed a trial of void but did complain of hematuria because of a traumatic Foley insertion.  He also complained of abdominal pain and refused opioid pain medications.  He requested to be admitted overnight for pain control.

The operative note indicated the patient underwent laparoscopic repair of incarcerated umbilical hernia and right inguinal hernia (RIH).  The findings were indirect and umbilical hernia with incarcerated omentum.  The pre-peritoneal approach was used for the RIH and mesh was placed. He had a primary closure of the umbilical defect reinforced with Parietex mesh as well as reinforcement of diastasis without primary or percutaneous closure.  A truncal nerve block was placed by anesthesia as well at the end of the case. 

Postoperative he did well and was placed on oxygen via nasal cannula (NC) because of desaturation.  He did complain of penile bleeding with bloody urine from traumatic Foley.  He was ambulating and voided tea colored urine.  The patient was tolerating oral intake.  He was placed on continuous positive airway pressure (CPAP) overnight.  He continued to do well.  His urine cleared and he was tolerating a diet and was to get out of bed (OOB).  Pain was controlled and he was discharged to home after a period of hemodynamic stability.

Based upon the records provided the patient did not require inpatient hospital admission but rather 23-hour observation.  He did not require inpatient admission as he had requested to be kept overnight and this could have been done with a 23 hour observation. He did pass the trial of void and having rust color urine was not an indication for admission. In addition pain control could have been done without an acute inpatient admission.

In addition, MCG Health General Recovery Guidelines 25th edition General Surgery or Procedure,  notes that Operative Status Criteria is ambulatory for many procedures.  Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma  repair, Fistula repair, Lymph node surgery; Hernia repairs in the absence of ALL of the following: Emergency procedure (e.g. strangulated hernia), Severe co morbid disease (e.g., severe infection), Complex approach (e.g., morbid obesity, large chronic incarceration); Hemorrhoid or rectal surgery; Most breast procedures; Percutaneous and dilation procedures; Liver biopsy.  In this case he could have been managed as an outpatient with a 23 hour observation without acute inpatient hospitalization as this surgery is an ambulatory status. 


To summarize the denial for coverage for the inpatient stay is upheld as the inpatient stay was not medically necessary as the patient could have been treated with a 23 hour observation/ ambulatory status.  Based upon these findings the health care plan did act reasonably and with sound medical judgment.   This patient did not require acute inpatient admission. 

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