Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inguinal Hernia. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

According to the patient's medical record, this patient with a past medical history of bilateral inguinal hernias and hypothyroidism presented to the emergency room (ER) with complaints of intermittent pain in a left inguinal hernia. He was originally scheduled for an inguinal hernia repair. The patient was admitted. As per the triage note, the patient was afebrile with stable vital signs and complained of left lower quadrant pain for 24 hours. The patient denied nausea, vomiting, and diarrhea. As per the ED provider note, the patient follows with a doctor and was told to come to the emergency department (ED) for surgery admission and hernia repair. The patient denied vomiting, fever and was having normal stool. On exam the abdomen was soft non-distended, and no palpable hernias were noted. Chest x-ray (CXR) revealed no significant findings. The patient was admitted with left incarcerated inguinal hernia and the plan was to keep NPO [nothing by mouth], administer intravenous (IV) fluids, provide pain control and prep for surgery.  General surgery noted the history noted that the patient recently visited the ED for incarcerated left inguinal hernia and today stated that he was unable to reduce the hernia and had felt worsening pain since yesterday. The patient denied nausea, vomiting or fever. The exam revealed the abdomen to be soft, non-distended, with left inguinal hernia which was minimally tender which was reduced at the bedside. The plan was operative repair and admit. White blood cells (WBC) was 9.5 and the rest of the labs were unremarkable. 

The patient was taken to the operating room for an open left inguinal repair with mesh with findings of a very large indirect hernia and moderately sized direct space hernia both of which were repaired as per the operative note. He tolerated the procedure and pain was controlled after surgery. He was able to tolerate a regular diet, void, pass flatus and ambulate. He was discharged after a period of hemodynamic stability. 

Based upon the records provided, the patient did not require inpatient hospital admission but rather 23-hour observation. He was admitted and had the surgery and was discharged later that day. All of this could have been done in an observation/ambulatory setting without inpatient admission. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 25th Edition Hernia Repair (Non-Hiatal) S-1305, the operative status criteria is ambulatory. 

The patient could have been managed as an outpatient with a 23-hour observation without acute inpatient hospitalization as this surgery is an ambulatory status. The hospital used the guidelines of abdominal pain, undiagnosed as the criteria for inpatient care. This was not a case of undiagnosed pain as the pain was from the inguinal hernia. Therefore, the hospital referenced criteria were not appropriate in evaluating this case. 

The health care plan did act reasonably and with sound medical judgment.  This patient did not require acute inpatient admission. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.