Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Hernia
Inpatient Hospital

The patient is a male, with a history of hypertension, who presented to the emergency department with a bulging mass in the left groin. Apparently, this has been present for a prolonged period of time, however, the swelling was reducible. Over the past several weeks prior to coming in, it became larger and became associated with some pain and discomfort. Cough or strenuous activity exacerbated the pain and made the swelling worse. There is no associated nausea or vomiting or diarrhea with this.
On exam, the temperature was 98.2, heart rate was 70, and blood pressure was 126/82 with respiratory rate of 20. The patient was described as a well-developed well-nourished individual, with a normal cardiovascular exam. Gastrointestinal (GI) exam shows a soft nontender abdomen with normal bowel sounds and left reducible inguinal hernia. White blood cell count was 6.7, hemoglobin was 16.5, electrolytes and renal function were normal. Liver function tests (LFTs) were normal as well. Urinalysis showed no evidence of infection. The patient was diagnosed with a unilateral inguinal hernia without obstruction or gangrene, however producing pain and discomfort on exertion. There was no clinical evidence of strangulation or obstruction. Surgery was consulted for hernia repair. The patient was cleared from a medical standpoint to undergo surgery. A computed tomography (CT) scan of the abdomen was done with oral contrast as well as intravenous (IV) contrast, which showed no bowel obstruction, enlarged prostate gland, and no further intra-abdominal pathology. A chest x-ray was also done, which was clear.
The patient was seen by surgery and felt the patient would benefit from left inguinal hernia repair. The patient was made nothing by mouth (NPO) status and scheduled for surgery later that day. The surgery was completed without difficulty. However, the patient continued to complain of left groin pain. The following day he was evaluated by pain medicine, who recommended Toradol 10 milligrams (mg) p.o. every 8 hours, Percocet, stool softeners and early ambulation.
The patient's vital signs remained stable, without fevers. Unfortunately, the patient did not tolerate the oxycodone, developed nausea, and a brief hypotensive episode. Oxycodone was discontinued.
On a postoperative day 2, the patient complained of feeling cold and shivering, as well as pain at the operative site. The temperature was 99.2, heart rate of 74, blood pressure 123/73, with respiratory rate of 16. Laboratory studies remain normal. The patient was cleared for discharge by surgery on this day.
The patient was discharged the following day home with prescriptions for ketorolac and acetaminophen as well as Percocet.
The issue at hand is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

This patient presented to the hospital, with a painful inguinal hernia, which was neither strangulated nor incarcerated. The hernia was fully reducible. This procedure was done in the hospital, to expedite relief of the patient's symptoms, not necessarily due to medical emergency or urgency. Hernia repair surgeries are typically done at a lower level of care status and do not require inpatient hospitalizations unless there is bowel strangulation, incarceration with gangrene. This was clearly not present in this patient, therefore there is no indication for inpatient hospitalization.
In conclusion, the hospitalization could have been managed at a lower level of care status and does not require an inpatient level of care.