Diagnosis: GERD; Hiatal hernia
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The medical record does not support that inpatient admission was medically necessary for this patient. The care and treatment provided could have reasonably and safely been provided with an outpatient level of care. This level of care would have permitted overnight hospitalization, post-operative follow up, advancement of diet, and provision of IV fluid, analgesics, and anti-emetics.

This patient underwent uncomplicated laparoscopic repair of a hiatal hernia and Nissen fundoplication. There is no clinical documentation to support need for inpatient admission. The patient remained hemodynamically stable throughout the perioperative period. There was no fever or aberration of vital signs. This patient's clinical needs could have been satisfied with an outpatient or observational level of care. The records support that the care provided was clinically appropriate. It is the level of care (inpatient vs outpatient / observational) that is at issue in this case.