Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post-surgery (to repair hernia)
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult female who presented to the emergency department with complaints of abdominal pain of two days duration. The patient had bariatric surgery eleven years ago (roux en Y gastric bypass) as treatment of morbid obesity. The patient's vital signs were reportedly normal at the time of emergency department presentation (her heart rate was reported as 70 beats per minute). The emergency department provider notes describe a tender abdomen. The patient's white blood count was 3.9 k/uL (kilo per microliter). A computed tomography scan showed findings consistent with a prior roux en Y gastric bypass and swirling of the mesentery, consistent with mesenteric volvulus related to an internal hernia. Comorbid health conditions included hypothyroidism, obesity, constipation and back pain. The records indicate that the patient underwent laparoscopic reduction and repair of the internal hernia on day number 2. The anesthetic record documents that the operation required approximately 1.5 hours to complete. The operative dictation describes closure of a patent Petersen space defect. The patient remained hemodynamically stable with normal vital signs following surgery. On day number 3, the patient reportedly had normal vital signs, and her pain was well controlled. The diet was advanced. The discharge summary states that the operative and postoperative course was uncomplicated, and she was cleared for discharge home with self-care. As per a denial letter, the health plan denied the requested inpatient admission, by stating it is not considered medically necessary, as the patient reportedly remained stable while being monitored. The appeal material references Milliman Care Guidelines. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

This patient had an internal hernia related to prior roux en Y gastric bypass that was performed eleven years ago. The patient presented to the hospital due to abdominal pain symptoms. She was hemodynamically stable at the time of presentation. Her evaluation included an abdominal computed tomography scan which identified the diagnosis of an internal hernia and established the indication for operative intervention. The operation to repair the internal hernia was performed on day number 2 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 following a period of recovery. In this case, the patient was clinically stable at the time of presentation. While she did require emergent surgery, the operation was performed without complication. Lab data prior to surgery and following surgery identified a slightly low white blood cell count that did not require an inpatient designation, and the patient was clinically stable for discharge from the hospital on the first post-surgical day. There were no complications of surgery or active comorbidities that required inpatient care. The patient responded promptly and favorably to the therapy provided. In this case there is no documentation to support that criteria existed to warrant an inpatient level of care. The care during this time could have been rendered at a lower level of care.