Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hiatal Hernia, Gastroesophageal Reflux Disease.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of hiatal hernia, gastroesophageal reflux disease (GERD), hypothyroidism, depression, pre-diabetes, morbid obesity, and status post gastric bypass. The patient presented to the hospital for a scheduled elective laparoscopic hiatal hernia repair with Nissen fundoplication. The patient underwent laparoscopic robotic assisted Nissen fundoplication/hiatal hernia repair. It was reported that the patient had adhesions between the liver and the gastric pouch which were taken down. The patient tolerated the surgery and was resting comfortably with stable vital signs. The patient's abdomen was soft, non-distended and tender to palpation over the incisions. An upper gastrointestinal series (UGIS) was performed the morning after the surgery which was negative for leak or obstruction. The patient's diet was advanced to clear liquids. The patient tolerated the diet well and was discharged home.

Based on the review of the medical records and literature, the inpatient admission was not medically necessary as the patient could have been monitored in a 23 hour observation status. According to the MCG guidelines for Fundoplasty, Esophagogastric, by laparoscopy ORG: S-505 (ISC), the operative status criteria for this procedure was ambulatory. Extended Stay was defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) with inpatient stay may be needed for: Conversion of procedure to open fundoplication procedure; Repair of paraoesophageal hernia required; Patient with high anesthesia risk; Patient with strictures or large hiatal hernias; Operative or postoperative complications, such as wrap herniation, pneumothorax, perforation, hemorrhage, or splenic injury requiring inpatient evaluation and care; Failure to achieve discharge status criteria. However, in this case, there were no criteria based upon these factors that would have warranted this patient for inpatient stay. 

The MCG General Recovery Care 24th Edition Ambulatory Surgery exception criteria GRG: CG-AEC (ISC GRG) noted that a potentially ambulatory procedure or surgery warrants inpatient care due to  1 or more of the following: Preoperative situation, condition, or finding that warrants inpatient stay as indicated by 1 or more of the  following: Inpatient care needed for preoperative disease or condition; emergent procedure; complex surgical approach or situation anticipated; procedure is not low risk and patient at high anesthetic risk; presence of drug-related risk; inadequate outpatient care situation; postoperative event, condition, or finding that warrants inpatient stay. In this case, the patient did not have any of these criteria that would have necessitated the procedure requiring exception criteria from an ambulatory status. Therefore, in this case, the patient did not require an inpatient setting and hospital services, and could have been cared for in an ambulatory setting.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient hospital stay is not substantiated.  The insurer's denial should be upheld.