Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld. 

This female patient has a history of left sided inguinal hernia as well as right-sided inguinal hernia. She presented to the emergency department (ED) with complaints of groin pain, rated at 9/10, non-radiating and worse with movement of the right lower extremity (RLE). The patient had previously undergone incarcerated inguinal hernia repair.

The patient presented with sharp pain in the right groin. She denied fever or chills, abdominal pain, nausea or vomiting, diarrhea or constipation. She had a prior open left inguinal hernia with mesh and a history of a small hernia in that area but now it had been getting larger. She stated she can usually reduce on her own but this day she was unable to. She was passing stool. On exam she was afebrile with right sided inguinal hernia that was tender to palpation. The concern was incarcerated/strangulated loops of bowel due to the hernia. General surgery noted the history and that the right-sided hernia was always in the past reducible and not associated with pain. The mass was seen and could not be reduced. There were no erythema or skin changes over the mass. The white blood cell (WBC) count was 7.7. A computed tomography (CT) scan of the abdomen and pelvis was done and revealed a right inguinal hernia containing mildly indurated fat. There was no bowel within the hernia. 

The patient underwent right inguinal hernia repair with mesh. The findings were indirect fat containing inguinal hernia. The patient did well post op, tolerating diet, afebrile and hemodynamically stable. She was able to ambulate to the bathroom and void freely. The patient's pain was well controlled. 

According to MCG Health Inpatient and Surgical Care 24th Edition Hernia Repair (Non-Hiatal) ORG: S-1305 (ISC), the operative status criteria is ambulatory for almost all patients undergoing inguinal, femoral, or umbilical hernia repair as they can be treated on an outpatient basis, as well as some patients undergoing ventral (primary and incisional) hernia repair. However, inpatient may be warranted for emergent procedures, very large ventral hernias, poorly controlled co morbidities that require inpatient-monitoring, morbid obesity, or if significant surgery beyond hernia repair is needed. Some patients undergoing repair of a recurrent ventral or incisional hernia, or open repair of an incisional or ventral hernia requiring mesh implantation may require inpatient care. In addition, some patients over the age of 65 undergoing repair of an incarcerated or strangulated (without infarction) femoral, incisional or ventral hernia, may require inpatient care.  

There was no other indication that the patient needed an acute admission as the patient had incarcerated fat in the inguinal canal and not bowel. She did not have any evidence of strangulation with infarction and therefore this could have been done in an observation setting with discharge within 23 hours. The hernia did not meet the criteria for inpatient admission as this could have been done in the ambulatory setting with observation for 23 hours. 

This patient could have been managed as an outpatient with an observation without acute inpatient hospitalization as she could have had the hernia repaired and sent home within a 23 hour observation. 

This patient underwent an uneventful repair of inguinal hernia with mesh which could have been done in an observation status and not an acute admission. She had her surgery early in the morning and could have been discharged later that day. She met all criteria for a safe discharge. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.