Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inguinal Hernia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient presented to the emergency department (ED) with the complaint of right groin lump for the past month. As per the ED provider note the patient presented complaining of right inguinal hernia which was out again and causing pain. He was able to self-reduce and the patient denied fever or chills. The patient denied vomiting but did note that he was advised by his surgeon to come to the ED. The assessment was inguinal hernia, and the plan was for admission and to require surgery. The nursing note does indicate the patient walked into the ED for hernia repair. As per the medicine consult the patient has hypertension (HTN) and hyperlipidemia (HLD) with a history of right groin lump for 1 month which has become painful while lifting but otherwise reducible. Vital signs were stable, and the patient was afebrile. The abdomen was soft with a reducible hernia noted. Labs were unremarkable. The patient was cleared for surgery. 

Surgery saw the patient and noted the history and that he had been seeing a surgeon in the outpatient office for his current complaint and was sent to the ED for planned surgery. The plan was for surgery. 

The Physician Assistant  noted that the surgery was postponed until tomorrow. 

Progress notes indicated the patient was admitted overnight for hernia surgery and he denied pain. 

The patient was taken to the operating room for robotic assisted lap right inguinal hernia repair with mesh and lap tap block. Postop note indicated the patient was doing well, the patient denied pain, vomiting and was tolerating diet. The patient tolerated the procedure well. The patient was monitored and medicated after surgery. Per surgical attending the patient was okay for discharge with follow up in 2 weeks. Follow up note indicated the patient denied to be discharged because he felt dizzy. His Blood Pressure was 130/70. 

Progress notes indicated the patient was doing well. He was ambulating and voiding. The plan was to be discharged to home today.  The patient was discharged.  

The patient did not require inpatient hospital admission. He was admitted as he was complaining of pain from the hernia. He was sent by his surgeon to the ED. This surgery could have been done electively. This was a reducible hernia and was not even incarcerated. There was no indication for an acute inpatient admission but rather elective planned surgery. This hernia repair should have been done on an observation/ambulatory setting without inpatient admission. The patient presented and the surgeon then postponed the surgery until two days later. The patient was discharged but this could have been done with an observation status and not an acute inpatient admission. 

This patient did not require acute inpatient admission as observation status was all that was necessary and therefore denial is upheld. In fact, one could even question if he needed an acute admission via the ED as this was not an in incarcerated or strangulated hernia. The surgery was not an emergency operation as there was no indication for this to be done as an emergency operation. The hernia was reducible, and pain was not an indication in this case for emergency surgery. 

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 the inpatient hospital admission is not substantiated.