Diagnosis: Left inguinal hernia.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is upheld.

The patient is a male. His medical history included schizophrenia and bipolar disorder (with a history of hallucinations/delusions/psychoses and pharmacologic non-compliance); overweight/obesity; and tobacco use. Despite "no emergency complaints," he was, "sent in for pre-op admission as he is planned to have elective hernia repair," for a chronic, asymptomatic, incarcerated, fat-containing, left inguinal hernia.

The patient's vitals were as follows: Temperature 36.5, pulse 82, blood pressure 109/67, respirations 18, oxygenation 99%, pain 0/10. Physical examination demonstrated a left inguinal hernia.

The patient was admitted at an acute inpatient level-of-care for elective inguinal hernia repair. He was deemed, "UNSAFE FOR DISCHARGE OR UNABLE TO BE COMPLIANT WITH OUTPATIENT THERAPY. Unable to be Complaint with Outpatient Medical Treatment as a Result of: Underlying psychiatric issue, Poor social supports and low health literacy." Indeed, previously, "Per psychiatry patient received Invega sustenna injection 11/12 IM [intramuscular], long term and will not need repeat injection." Despite the fact that the patient wanted to undergo repair, he eloped.

No, the Inpatient admission was not medically necessary.

The patient did not require admission for either his hernia or his mental illness.

The patient was stable with normal vital signs and no evidence of physiologic derangements. The patient did not report any symptoms or complications associated with his hernia -- no pain, no gangrene, no obstruction.

The patient did not report any acute mental health changes -- "no emergency complaints." The patient received long-acting psychiatric medications and did not need re-treatment until after the dates-in-question -- "Per psychiatry patient received Invega sustenna injection 11/12 IM [intramuscular], long term and will not need repeat injection."

Therefore, despite a history of hallucinations/delusions/psychoses and pharmacologic non-compliance, there was no need for admission at an acute inpatient level-of-care. In the setting of clinical stability, the patient could have been treated at a lower level-of-care.

Despite a history of hallucinations/delusions/psychoses and pharmacologic non-compliance, there was no need for admission at an acute inpatient level-of-care. In the setting of clinical stability, the patient could have been treated at a lower level-of-care.