Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 
The insurer denied the inpatient hospital stay. 
The denial is overturned in whole. 

The patient is a male with multiple medical problems including human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART), hepatitis C, polysubstance abuse with methadone dependence, asthma, bilateral lower extremity ulcers, hyperlipidemia, and a heart murmur. He has a long-standing history of a right inguinal hernia. The patient presented to the Emergency Department (ED) with complaints of bloody emesis (hematemesis) and right groin pain. He underwent a computed tomography (CT) scan of the chest/abdomen/pelvis that showed no evidence of active bleeding as well as a right inguinal hernia containing a non-dilated loop of small bowel. He was diagnosed with a Mallory Weiss tear, and he was prescribed a proton pump inhibitor and given instructions to follow-up for an endoscopy as an outpatient. It is not clear if he was discharged from the ED or if he left against medical advice.

The patient returned to the ED, again with complaints of multiple episodes of (hematemesis) and right inguinal pain that reportedly started 3-4 days prior to presentation. Upon evaluation, he was found to be afebrile with normal vital signs. He was described as being in moderate distress. The abdominal examination was soft, with the presence of an irreducible right inguinal hernia. An attempt at manual reduction of the hernia was made without success. He was diagnosed with an incarcerated inguinal hernia for which he was admitted to the hospital in anticipation of a robotic right inguinal hernia repair to be performed the next morning. Laboratory studies revealed mild leukocytosis at 12.8, acute kidney injury with a creatinine of 1.5 (elevated), potassium of 5.2 (elevated) and a lactic acid of 1.0 (elevated).

During his hospitalization, the patient received intravenous (IV) hydration and IV pain medications with a plan to proceed with a robotic inguinal hernia repair. He was waiting for his surgery to be performed and he complained of not receiving his methadone and not being able to smoke. The patient left the hospital against medical advice despite counseling as to the risks of not proceeding with the recommended operation.

At issue is the medical necessity of the inpatient hospital stay.

The health plan's determination is overturned in whole.

The requested health service/treatment of inpatient hospital stay was medically necessary for this patient.

The inpatient level of care was medically necessary for this patient due to his acute surgical emergency of an incarcerated hernia with dehydration and acute kidney injury, in addition to multiple medical comorbid conditions and psychosocial issues related to his polysubstance abuse and methadone dependence.

The patient returned to the ED with similar complaints as previous, and attention was turned to the persistent right inguinal pain and the presence of an irreducible (incarcerated) hernia that was unable to be manually reduced. An acutely incarcerated hernia is considered a medical emergency due to the risk of progression to strangulation of the hernia contents. An acute inpatient admission was medically necessary for this patient due to his surgical emergency of an incarcerated inguinal hernia containing a loop of bowel, for which close monitoring was required up until his planned urgent surgical intervention. The patient also exhibited signs of dehydration with acute kidney injury requiring IV fluid resuscitation, likely as a result of his vomiting and poor oral intake prior to his presentation. 

Therefore, the requested health service/treatment of inpatient hospital stay was medically necessary.