Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hiatal Hernia

Treatment: inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld.

According to the documentation submitted, this patient has a history of systemic lupus erythematosus (SLE), asthma, hiatal hernia, morbid obesity, status post gastric bypass surgery.  The patient presented with stable vital signs with a body mass index (BMI) of 35.6.

Surgery started and was completed and the patient underwent an esophagogastroduodenoscopy (EGD), laparoscopic (lap) insertion of gastric band with port as per the post procedure note. The operative dictation indicated lap insertion of lap band, lap repair of hiatal hernia and EGD was done. Intraoperative endoscopy was done after insertion of lap band and did not reveal evidence of gastric outlet obstruction or perforation to the gastric pouch with a normal roux en y gastric bypass anatomy. In terms of the hiatal hernia repair the operative note indicated that the crura was approximated with Ethibond stitches. No fundoplication was performed.

Based upon the information provided, the inpatient admission is not approved as it was not medically necessary for in-patient care but rather observation 23-hour status. The patient came to the hospital for elective laparoscopic (lap) band port insertion and EGD with repair of hiatal hernia. Surgery was uneventful and she was discharged. Her post-surgical treatment could have been done without an acute admission but rather an observation status.  Therefore, the inpatient admission was not necessary. 

According to MCG (Milliman Care Guidelines) Health General Recovery Care 25th Edition General surgery or procedure for discharge criteria, continued inpatient stay is needed until 1 or more of the following are present: Acceptable patient status for next level of care is achieved; ALL of the following are present: Operative site and other wounds acceptable, Pain and nausea absent or adequately managed, Temperature status acceptable, No infection, or status acceptable, No blood loss, or problem resolved, Abdominal status acceptable, Hepatic and biliary abnormalities absent or acceptable, Inflammation absent or stable (e.g., colitis), No transplant done, or status acceptable, Activity level acceptable, Intake acceptable, No inpatient interventions needed, General Discharge Criteria met.  This patient did not need acute care services or continued care as she met criteria for discharge. Thus, this patient could have been treated in an ambulatory status with observation. Furthermore, as noted by MCG Inpatient and Surgical care 25th edition Gastric restrictive procedure without gastric bypass by laparoscopy ORG: S-515 (ISC), the lap band is considered an ambulatory procedure. Therefore, in this case the insertion of the lap band, and repair of diaphragmatic opening with Ethibond stitches required only an ambulatory status and not an inpatient admission. 

Finally, according to MCG health Inpatient and surgical care 25th edition Ambulatory surgery discharge and complications: common complications and conditions) Surgery or procedure performed on ambulatory basis may require inpatient stay for 1 or more of the following: Preoperative situation, condition, or finding that warrants inpatient stay; or postop perspective that the patient required inpatient stay rather than just observation status.  She did not require an acute care admission and only observation as she did not have an acute medical condition preoperatively or post operatively that required inpatient status and she did not require postop and inpatient stay but rather observation status for pain management control. 

Based upon the clinical information provided the inpatient admission was not justified at the acute level as the patient could have been treated in an observation status.  The patient did not need acute inpatient hospitalization. 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient in denying this admission. 

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