Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incarcerated Hernia

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

According to the patient's medical record, this patient has a past medical history of morbid obesity, hypertension and coronary artery disease.  She presented to the hospital on for a scheduled repair of an incarcerated hernia.  Preoperative in the holding area her blood pressure (BP) was 202/87 and repeated it was 187/89.  The plan was as per surgeon and anesthesiologist to monitor and control the BP in the operating room.  The hernia contained intestines and was not fully reducible in the office.  It also had some fluid which indicated chronic incarceration. The body mass index (BMI) was greater than 40 and that she was high risk for recurrence.  The operative note indicated that prior to the surgery the patient did undergo cardiac and pulmonary evaluation.  It was noted that she did have an area on stress test of mild reversible ischemia.  Her cardiologist felt that no further investigation was needed and that he could proceed with surgery.  An open repair of an incarcerated incisional hernia with mesh implantation and diagnostic laparoscopy (aborted laparoscopic [lap] attempt) was performed.  The lap approach was aborted because there was a dampening of the arterial line and a fall in the blood pressure that required a pressor dose.  Thus, after the second or third time, it appeared to be related to the pneumoperitoneum and the decision was made to abort and do an open approach.  The patient had severe adhesions within the hernia defect which precluded safe reduction of the hernia contents.  Repair was done through a 5 inch midline incision over the hernia that was to the right of periumbilical area.  The surgeon noted that given her severe obesity and the fact that she had incarcerated bowel inside the hernia sac that was now reduced he felt the best approach was an underlay bridging repair with mesh.  The operative note did indicate that there was 6 centimeter (cm) defect.  Two drains were placed.  
According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 25th Edition Hernia Repair (Non-Hiatal), inpatient stay may be needed for: Emergent surgery for patient with strangulated hernia, or other evidence of ischemia or infarction of hernia contents, may require continued inpatient care. Open repair of large, recurrent or incarcerated ventral or incisional hernia and one can expect brief stay extension; Morbid obesity (e.g., BMI greater than 40) with morbidly obese patients are at risk for complications. Given the above inpatient stay was warranted for this patient as this patient had extensive adhesions and required an open repair for a large defect and was morbidly obese with active co morbidities.  Thus, in this case ambulatory surgery was not warranted but rather inpatient with monitoring. 

The patient could not have been managed as an outpatient with a 23-hour observation without acute inpatient hospitalization as she was morbidly obese and had a large chronic incarcerated hernia. 

To summarize the denial for coverage for the inpatient stay was medically necessary.  The health care plan did not act reasonably and with sound medical judgment.  This patient did require acute inpatient admission and denial is reversed.

The insurer's denial of coverage for the inpatient hospital admission Hospital is reversed.  Medical Necessity is substantiated.