Hernia: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management Procedure (CPT 43284).Findings: Two out of three physician reviewers found that the current medical evidence supports the requested service in this clinical setting. This patient has fulfilled eligibility criteria for the LINX Reflux Management Procedure since he has typical GERD symptoms, an abnormal pH study, intolerance to PPI therapy and absence of a large hiatal hernia. The requested service has been shown to be superior to twice-daily PPI therapy. Bell and colleagues compared the effectiveness of increased PPI dosing with laparoscopic magnetic sphincter augmentation in patients with moderate-to-severe regurgitation despite once-daily PPI therapy.

Findings: The physician reviewer found that The patient has requested reimbursement for abdominal wall reconstruction surgery. Emanuelsson and colleagues state, “Functional disability related to midline bulging of the abdominal wall is a common complaint in women after childbirth. Abdominal rectus diastasis (ARD) is a sequela of the expansion of the abdominal contents during pregnancy. Massive weight loss and/or congenital disproportion of the collagen III/I ratio may also result in ARD.” The authors found no consensus on whether ARD should be considered a pathologic condition requiring operative attention. Strigård and colleagues state, “The clinical significance of abdominal rectus diastasis (ARD) is debatable.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for immediate admission to an acute care hospital.On review of the available documentation, there is a lack of support for the requested immediate admission to an acute care hospital, for either the patient’s hernia or seizures. Typically for hernias, emergent surgery is indicated with incarcerated or strangulated hernias, but otherwise a planned surgery is recommended so the patient can be appropriately prepared for surgery to minimize risk. Although the patient may meet the criteria for surgical hernia repair, the patient should be referred to an in-person visit with the provider to be appropriately evaluated and triaged.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hernia surgery. Findings: The physician reviewer found that Surgical repair of the ventral hernia is not recommended for this patient since the medical literature and guidelines have reported that hernia repair in patients with body mass index (BMI) greater than 35 kg/m2 is associated with high degree of recurrence, need for additional surgery, and increased morbidity. The available records document that this patient’s hernia is longstanding, contains only fat and is large in size. The provider’s description of the patient’s hernia suggest that it poses less risk of likely obstruction or incarceration, particularly since it is documented to be filled with fat. The patient has a BMI that is greater than 35 kg/m2, which places her at high risk of failure of ventral hernia repair.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for hernia was denied, the published record says the denial is worth fighting.