Appeal type: Medical necessity
Decision: Upheld

Diagnosis: After procedure monitoring
Treatment: Inpatient admission
The health plan denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with past medical history of morbid obesity who presents to the emergency department with abdominal pain. The patient has a history of recurrent ventral repairs complicated with seromas that were drained. Her physical examination showed abdominal pain in the suprapubic region with fluctuance consistent with a seroma. The patient's laboratory studies were normal. The patient did not have an abdominal or pelvic computed tomography (CT) scan done. She went to the operating room for an incision and drainage of an abdominal wall seroma. The wound was packed. The patient was discharged from the post-anesthesia care unit.

The patient was evaluated in the emergency department. Her physical examination showed suprapubic pain related to a seroma. She underwent a simple incision and drainage procedure in the operating room. She was discharged home from the recovery room. The patient did not need any monitoring as she was discharged home from the post-anesthesia care unit (PACU).

The requested health service and treatment of an inpatient admission was not medically necessary for the patient. The patient has a medical history of morbid obesity status post ventral hernia repair. She has had previous incision and drainage procedures for seromas in the past. She was evaluated in the emergency department. Her physical examination showed suprapubic pain related to a seroma. She underwent an incision and drainage procedure in the operating room. The patient did not need any monitoring as she was discharged home from the PACU.
Seromas occur in 2.9 percent (%) of open umbilical hernia repairs and 3.5% of open epigastric hernia repairs. The incidence of a seroma in the laparoscopic group is higher, at 10%.
Seromas can be tender or uncomfortable to the patient. They can also become secondarily infected in both the open and the laparoscopic procedures, ultimately requiring removal of the mesh and there can be a recurrence of the ventral hernia. Treatment by aspiration or repeated aspiration of the seroma can be uncomfortable and annoying to the patient and has the risk of introducing bacteria.
Most seromas will resolve with expectant therapy. Symptomatic seromas, large seromas and persistent seromas can be aspirated. Repeated aspirations of the seroma might be required. A chronic seroma might need operative intervention using the open or laparoscopic approach with drainage of the fluid and removal of the pseudo capsule.
Placement of subcutaneous drains has been advocated in the open repair that requires extensive dissection and the development of flaps in order to prevent fluid accumulation. The use of a pressure dressing with a binder for 7 to 10 days after laparoscopic repair has also been advocated.  Premature removal of a drain can result in fluid accumulation, however, this should be weighed against leaving a drain in for a prolonged period of time with the potential for an infection to occur. A small study suggested that cauterization of the hernia sac during the laparoscopic repair prevents seroma formation (Itani 2009).