CLINICAL SUMMARY: Post-Surgery Inpatient Admission Deemed Medically Unnecessary Overturned
A 52-year-old patient underwent a planned ventral incisional hernia operation, performed laparoscopically using an intraperitoneal onlay mesh placement. The patient was classified as ASA Class III, defined by the American Society for Anesthesiologists (ASA) for patients with “severe systemic disease that is not incapacitating” with a history of diabetes mellitus (DM). Since the surgery was a scheduled procedure, the labs taken for admission were K+ (4.0) and Glu range (118-151). Doctors performed an uncomplicated surgery and the patient responded well but was in severe pain that required IV medication. Doctors prescribed Dilaudid patient-controlled analgesia (PCA) for pain control and IV fluids. After the procedure, WBC 15.41, Hgb 13.4, Na 139, K 4.2, Mg 1.7, BUN 11, Cr 0.69, Glu 97. On post-operative day one, doctors deemed the patient stable and ready for discharge based on the patient’s ability to tolerate a regular diet, ambulate without difficulty and use of oral analgesics for pain.
DENIED INPATIENT STAY
DENIED INPATIENT STAYThe payer denied the one-day inpatient stay stating that it was “not medically necessary,” further elaborating that a full hospital admission after surgery would be needed only when a patient needed additional surgery or in the case of severe problems. The payer – which used MCG guidelines for hernia repair (non-hiatal) ORG: S-1305 – went on to define severe problems as including “severe pain needing frequent medicines through the vein.” The payer denied the inpatient admission stating that the information provided did not show medical necessity for this level of care.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAppriseMD completed a peer-to-peer discussion with the insurance company medical director to review the denial and the payer’s reasons. AppriseMD pointed out the patient did meet the payer’s inpatient stay status defined by MCG guidelines for hernia repair (non-hiatal) since “severe pain needing frequent medicines through the vein” was present. The patient required IV fluids and Dilaudid PCA to manage the severe pain post-surgery. Furthermore, the patient’s ASA Class III status qualified the patient as high risk due to the presence of DM and a recent sigmoid resection for a fistula repair. After a lengthy discussion, the payer overturned the denial and approved the inpatient admission based on the need for Dilaudid PCA in a higher risk patient. For these reasons, despite the short one-night stay, the payer approved the inpatient level of care.