Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Cyst Incarcerated Umbilical Hernia.
Treatment: Inpatient stay.

The insurer denied coverage for inpatient stay.  The denial is upheld.

The patient is a female with a past medical history of asthma, anxiety/depression and congenital umbilical hernia status post-surgery at a young age, who presented to the Emergency Department with complaint of abdominal pain. The patient was admitted. The patient had a computed tomography (CT) scan the day prior to presentation, which showed fat containing umbilical hernia. The patient currently denied nausea/vomiting/diarrhea, fever, and chills. The patient stated the pain was severe, and she had to take multiple Percocet's without any relief. Vital signs were normal. On exam she had a palpable umbilical hernia that was tender and non-reducible. No bowel sounds were heard over the hernia. There was no guarding or rebound. White blood cell count was normal. The plan was to admit for the diagnosis of umbilical hernia incarcerated.

The patient was sent to the emergency department for an incarcerated umbilical hernia surgery by her doctor. On his assessment, he noted that the patient had acute recurrent umbilical abdominal pain secondary to most likely non-reducible incarcerated umbilical hernia.

Computed tomography scan had a fat containing umbilical hernia, 6 centimeters contents in the sac with a 1.5 centimeters fascial defect. He was unable to reduce the hernia in the office without significant pain. She denied fever, nausea, vomiting and the patient was hungry. The pain was localized to the hernia site. He noted that the patient was also seen recently by another physician who did a pelvic ultrasound and found a large ovarian cyst 5.5 centimeters in size. The patient believed that doctor said she may need surgery versus magnetic resonance imaging to further evaluate the adnexa. His plan was nothing by mouth past midnight for Operating Room next day.

The patient had a lap ventral hernia repair and lap ovarian cystectomy. Both operations were uneventful. A transversus abdominis plane block was also performed as well as exam under anesthesia lysis of adhesions and hysteroscopy. Path revealed benign ovary with follicular and luteal cyst formation.

Based upon the records provided, the patient did not require inpatient hospital admission, as the patient was sent to the hospital on for planned surgery and underwent an uneventful repair of umbilical hernia and excision of ovarian cyst, which could have been done in an observation status and not an acute admission. She had her surgery late on the second day of admission, having presented to the hospital the day before surgery date (first day of admission). She did not require being admitted for this as this is an outpatient procedure. She could have been discharged later after tolerating a diet and meeting all criteria for a safe discharge. The surgery was uneventful, and she should have been discharged following a 23 hour stay and not an acute inpatient admission.

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

The insurer's denial of coverage for the inpatient stay is upheld. Medical necessity is not substantiated.