Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventral Hernia
Treatment: Inpatient Hospital Admission. 
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

This patient is a male (body mass index (BMI) 28 kilograms per meters squared (kg/m2)) who presented to the clinic with complaints related to a reducible ventral hernia. His past medical history included asthma, atrial fibrillation, chronic lower extremity cellulitis, and a prior tracheostomy and gastrostomy. He was scheduled for an elective laparoscopic ventral hernia repair. His vital signs were normal at the time of presentation to the hospital.
The records indicate that the patient underwent a laparoscopic ventral hernia repair with 15 centimeter (cm) mesh. The anesthetic record documents that the operation required 2 hours and 21 minutes to complete. The patient was found to have an abnormality of the airway during intubation and an ear, nose, and throat (ENT) consultation was requested. The ENT notes state that the impression was that this was likely scarring from the prior tracheostomy and no intervention was required at this time.
He was monitored in the Intensive Care Unit (ICU) due to difficulty with the intubation. The patient remained hemodynamically stable with normal vital signs following surgery. On post operative day 1, he had normal vital signs and his pain was well controlled. The patient's diet was advanced. The patient was deemed to be stable for discharge from the hospital.
The submitted documentation references Milliman Care Guidelines (MCG) Gastroenterology 26th edition.

Based on the submitted medical record and the referenced Milliman Care Guidelines (MCG), the inpatient level of care was not required or medically necessary for this patient.
This patient had a reducible abdominal wall ventral hernia. The patient presented to the hospital to undergo the elective repair of this hernia. He was hemodynamically stable at the time of presentation. The operation to repair the ventral hernia was performed without complication. The submitted records document clinical stability in the perioperative period and that the patient met criteria for discharge from the hospital on the first post-surgical day. The ENT consultation for an airway abnormality yielded the impression that this was scarring from prior tracheostomy and did not require any intervention.
Per the submitted MCG guidelines, the inpatient stay is needed for hemodynamic instability, peritoneal signs, suspected acute mesenteric ischemia, foreign body ingestion with signs of obstruction, or other signs or symptoms of acute abdominal disease. Inpatient care may also be needed for acute appendicitis, ascites, severe diarrhea, severe dysphagia, gastroparesis, encopresis, complications of enteral feeding tubes, or complications of organ transplant. In this case there is no documentation to support that these criteria existed to warrant an inpatient level of care. The operation was completed without complications and the patient responded promptly and favorably to the therapy provided. He was stable for discharge from the hospital on the first post-operative day. The care during this time could have been rendered with an alternate level of care. An alternate level of care would have been consistent with the submitted MCG guidelines and with generally accepted medical standards.

The health plan's determination of medical necessity is upheld in whole.