Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 
 
The patient is an adult female status post gastric bypass, hypertension, hyperlipidemia, obstructive sleep apnea (OSA), asthma, lap (laparoscopic) cholecystectomy, umbilical hernia repair with mesh who presented to the ED (emergency department) with worsening abdominal pain. The patient stated the pain started 6 months ago as sharp pulling pan in her abdomen when bending over. At the same time, she noticed some increasing abdominal bloating with eating of certain foods. She stated she uses enemas regularly to pass gas or bowel movements. She has had some nausea but no vomiting recently. She is able to tolerate an oral diet without nausea or vomiting. Exam revealed the abdomen to be soft, obese, tender to palpation around the umbilicus with chronic skin changes, otherwise no rebound or guarding. The white blood cell (WBC) count was 7.3. CT (computed tomography) results were reviewed. The assessment was pain with chronic, recurrent ventral hernia. The plans were pain control, bowel prep and add on to OR (operating room) for open ventral hernia repair possible mesh. Pulmonary risk stratification was also needed. The patient was made NPO (nothing by mouth) past midnight.

Pulmonary saw the patient and evaluated her and noted that she was stable to proceed for planned procedure with intermediate risk for post op pulmonary complication. 

Nursing note indicated the patient did not complain of pain. The patient was given Golightly over night and had bowel movements all night. The pain was well controlled. Surgical progress note indicated the patient was preop for surgery today. 

The patient was taken to the operating room the next day and underwent open repair of incarcerated umbilical hernia with resection of old mesh and repair with physio mesh. 

Post op note indicated that they can start clear liquid diet and advance as tolerated. 

She did well and was discharged. 

Based upon the records, the patient did not require inpatient hospital admission as this was not an emergency as she had no evidence of bowel obstruction on CT. She was admitted and then consultation was obtained from pulmonary and surgery was delayed.  She had been complaining of pain for 6 months and there was nothing acutely different to require emergent admission and surgery. She was admitted and then given bowel prep. The notes indicated the surgery was to be done but it was not performed until hospital day 3. The entire procedure took approximately and hour and a half. She was then kept overnight and discharged. The patient could have had this scheduled electively including the bowel prep. Therefore, the inpatient admission should be denied as she required observation care only. In fact, she came to the ED tolerating a diet and was afebrile, with normal WBC and CT scan that did not show obstruction. She had this chronic hernia for some time. It did need to be repaired but this could have been done electively and not as a four-day inpatient admission. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Hernia Repair (Non-Hiatal) ORG: S-1305 (ISC), the operative status criteria is ambulatory.  

In addition, MCG Health General Recovery Guidelines 27th edition General Surgery or Procedure GRG: SG-GS (ISC GRG), notes that Operative Status Criteria is ambulatory for many procedures. 

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 an inpatient admission is not substantiated.