Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hernia
Treatment is inpatient surgery on the abdomen.
The insurer denied coverage for inpatient surgery on the abdomen.
The denial is overturned.

According to the documentation submitted, this is an adult with a history of Crohn's disease, hypothyroidism, obesity, obstructive sleep apnea (OSA), pulmonary embolism (PE), diabetes and ventral hernia. The provider noted that the patient reported a gynecological complication requiring a partial hysterectomy. The patient also reported an open cholecystectomy and a ventral hernia of 2 years' duration. The patient noted sharp, burning pain accompanied by a bulge. Examination noted a soft non-distended abdomen with a large tender reducible midline ventral hernia with separation of the rectus muscles. Computed tomography (CT) of the abdomen revealed thinning and diastasis of the abdominal wall musculature with a superimposed supraumbilical hernia containing fat. The assessment was that complex abdominal wall reconstruction was required for a large ventral hernia and separation of the rectus muscles. The patient was seen again via telemedicine visit. The patient now reported that the ventral hernia had gotten larger and was more tender. The patient saw a doctor who indicated that the patient's elevated liver enzymes were due to NASH (nonalcoholic steatohepatitis) and that a liver biopsy was to be added to the patient's upcoming surgery of complex abdominal wall reconstruction.

Based upon the submitted documentation, the patient will require inpatient hospital admission as the patient is undergoing a complex wall reconstruction. Although hernia repair should be done on an observation/ambulatory setting without inpatient admission, in this case and given the complexity of the operation the procedure, this would require inpatient admission. This defect is very large - 10 cm (centimeters) as noted by the surgeon.

Given the above, inpatient admission is warranted as this patient has an exceptionally large ventral hernia with diastasis recti requiring a complex abdominal wall reconstruction. It is not a simple hernia repair and therefore the providers are correct in advocating for an inpatient procedure. If the patient is able to go home in 24 hours, then it would not be unreasonable to consider this under observation; however, this would not be known until the procedure and postoperative care is completed. Therefore, it is only appropriate to approve for an inpatient stay for this procedure.

In addition, MCG (Milliman Care Guidelines) Health General Recovery Guidelines 26th Edition General Surgery or Procedure GRG: SG-GS (ISC GRG), notes that Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma  repair, Fistula repair, Lymph node surgery; Hernia repairs in the absence of ALL of the following: Emergency procedure (e.g. strangulated hernia), Severe co morbid disease (e.g., severe infection), Complex approach (e.g., morbid obesity, large chronic incarceration); Hemorrhoid or rectal surgery; Most breast procedures; Percutaneous and dilation procedures; Liver biopsy.  

Therefore, given the nature and description of the abdominal wall defect with a large ventral hernia with diastasis, the providers are correct in asking for an inpatient stay for this repair. Inpatient admission is medically necessary for this patient, given the nature of the repair for this large ventral hernia/diastasis recti. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for the inpatient surgery on the abdomen is overturned. Medical necessity is substantiated.