Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the Emergency Department with severe pain and a known left inguinal hernia which had remained small, reducible, and asymptomatic for several years. A Computed Tomography (CT) of the abdomen and pelvis noted a left inguinal hernia with fat stranding in the hernia sac concerning for an incarcerated left inguinal hernia. Surgery evaluation recommended repair. The patient received 2 doses of intravenous hydromorphone and one dose of ketorolac to help manage the pain. The patient underwent a left inguinal hernia repair and was discharged home the next day. 

The HerniaSurge Group is an expert group of international surgeons and an anesthesiologist from all continents with specific experience in hernia-related research. The group reviewed literature searches for level 1 publications to July 2015 and formulated recommendations and guidelines regarding the care of patients with inguinal hernias. The guidelines have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. Per these recommendations, "day surgery is recommended for the majority of groin hernia repair provided aftercare is organized." 

Ziga et al. performed a prospective, observational, two-center study comparing the outcome of outpatient and inpatient post-operative care in terms of the readmission rate, complication rate and quality of life in patients with primary unilateral inguinal hernia repair from January 2019 to April of 2020. Since 2018, AVOS (ambulant vor stationar = outpatient to inpatient) regulation has been progressively implemented in hernia surgery in Switzerland. In a total of 237 patients with a primary unilateral inguinal hernia, complications occurred in 11 (14%) inpatient patients, but none required readmission for revision until follow-up at 6 weeks after discharge. In the outpatient group, there were 27 (17%) complications reported, while 6 (4%) of these patients crossed over to the inpatient group immediately after surgery. None of the other complications required readmission until follow-up at 6 weeks. No significant relationship between treatment setting and number of complications/readmission rate (p=0.458, p=0.061) was observed. The authors concluded that primary unilateral inguinal hernia can be safely treated in both treatment settings, with no significant difference in readmission rates, complication rates, and quality of life. 

Per Meyerson, InterQual criteria define observation level of care as "hemodynamically stable patients who require 6-24 hours of treatment or assessment pending a decision regarding the need for additional care". Per Milliman Care Guidelines criteria, "inpatient admission or transition to inpatient admission from observation care is generally indicated when a condition (such as acute Myocardial Infarction or heart attack) is diagnosed requiring a longer-term stay or when longer-term treatment or monitoring is needed for a condition (such as persistent severe asthma)." This patient presented with a known left inguinal hernia that was successfully reduced in the emergency department, but which was accompanied by persistent pain. Surgical evaluation recommended repair of the left inguinal hernia. The patient remained hemodynamically stable with stable laboratory values while awaiting the surgery. The patient received intravenous hydromorphone and ketorolac without any evidence of hemodynamic instability, bowel obstruction, persistent nausea or vomiting, or bowel ischemia that would require further intervention or prolonged monitoring. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.