Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who was seen for a hernia. She had 5 previous Cesarean (C)-sections and had a hernia in her lower abdomen with pain. A computed tomography (CT) scan demonstrated bowel associated with the hernia. The surgeon recommended retrorectus repair. The patient was seen by her primary care physician (or provider) (PCP) prior to undergoing surgery. She underwent an open ventral hernia repair with component separation. There were no complications. The hernia size was noted to be 12 centimeters (cm). The patient was hospitalized overnight after the surgery. The patient's pain was controlled with intravenous (IV) pain medicines. The patient was placed on a clear liquid diet. On postoperative day 2, the patient began passing gas and her diet was advanced. She had low grade temperatures that night. The next day the patient was doing well. The pain was controlled on oral analgesics The drains were removed and the patient was discharged home.

The patient does not meet criteria for inpatient hospital admission.
The patient displayed no signs of the preoperative diseases or conditions commonly deemed clinically significant. She showed no indications of severe infections, altered mental status, or conditions such as dangerous arrhythmias, hypotension, or hypoxemia. There were no other discernable serious conditions that would typically necessitate inpatient care pre-operatively or postoperatively. 
In terms of the surgical approach, there was no anticipation of complex situations for the patient. The proposed procedure is not typically considered an unusually difficult procedure nor does it require prolonged airway monitoring. There are npt any factors suggesting the need for an extended period of postoperative care or additional monitoring at an inpatient level of care.
Considering the inherent risks of the procedure and anesthetic implications, the patient did not fall into any high-risk categories. Her health profile did not match the American Society of Anesthesiologists class III or above criteria, and she did not present with severe frailty, advanced age concerns, or any of the outlined significant systemic diseases. Notably, there was no evidence of severe renal diseases, morbid obesity-related issues, or any other conditions that could increase the anesthetic risk.
In relation to drug interactions and related risks, the patient was not on any medication regimen that would require discontinuation preoperatively. She had no history of using drugs that might adversely interact with anesthetics.
From a post-operative care perspective, there were no logistical issues. There was not document that the patient does not reside in proximity to the medical facility, ensuring easy access in case of emergencies. There was no documentation that her home environment was not well-equipped for postoperative recovery, and there was no incapacitation anticipated that might require additional in-home assistance. There was also no expectation of the patient needing extended general anesthesia that could potentially warrant additional postoperative oversight.
Looking at potential postoperative events or conditions, the patient was not anticipated to have complications such as inadequate physiological recovery, hemodynamic instability, respiratory abnormalities, or acute kidney injury. Her mental status post anesthesia was expected to remain stable, and no operative site complications were predicted.