Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cervical stenosis, cervical myelopathy and cervical radiculopathy

Treatment: inpatient surgical services provided by OON (out-of-network surgeons)

The insurer denied coverage for inpatient surgical services provided by OON surgeons

The denial is overturned.

The patient is a female with a history of cervical disc herniation, cervical stenosis, cervical myelopathy and cervical radiculopathy. She presented to the emergency room for neck pain to the right shoulder and upper extremity weakness, numbness and tingling. She reported a worsening of weakness and the inability to bring her arm over her head, could not hold onto a hairbrush or dry head with the right arm and had been dropping items. She felt it was rapidly worsening. Her ER (emergency room) exam noted decreased right grip strength. Another exam noted 3/5 strength right upper extremity with decreased sensation. The decision was to admit for surgery. She was surgically cleared by Medicine. She underwent an ACDF (anterior cervical discectomy and fusion) C (cervical)4-C7 with partial corpectomy. Her discharge note states an exam for right upper extremity deltoids down to the intrinsic hand muscles 4/5, inability to bring her arm overhead and increased reflexes in upper and lower extremity with positive Hoffmann sign.

She then had a significant change in her symptoms and felt like she was losing the use of her arm with severe pain and inability to sleep. She presented to the emergency room where she was told they needed to do surgery. She was being prepped for surgery where both doctors came in and he was the one that did the surgery. She did not choose to use him despite his status outside the network, she took whoever was arranged by the hospital. She was already prepped for surgery and in intense pain. She learned that there were no surgeons practicing at the hospital who would have been in network. She felt her surgery would fall under the surprise bill. 

The patient was seen outside the hospital and recommended surgery but not urgently. She had a dramatic increase in her level of pain and loss of function which led her to the emergency room where it was determined that emergent surgery was necessary. It was in his opinion, to a reasonable degree of medical certainty, this decision was correct because both the level of pain she reported and the neurological deficits she experienced when she arrived at the hospital were evidence that she was at high risk of permanent and irreversible loss of function should the surgery be delayed. A transfer to another institution for surgery would have been contraindicated because the move and associated stress could cause further spasm or compression that would render the deficits permanent. Her need for surgery as determined in the emergency room was urgent and based on her intractable pain and risk of permanent deficits, properly covered as an emergency.

The health care plan did not consider the severity of the patient, the clinical judgement of the surgeon or the rules of surprise bill and emergency services.  

Policy: Emergency Services:
"Emergency Condition": A medical or behavioral condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: 
	Serious impairment to such person's bodily functions;
	Serious dysfunction of any bodily organ or part of such person (1)

The insurer's denial of coverage for the inpatient surgical services provided by out of network (OON) surgeons overturned. Medical Necessity is substantiated.