Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical spondylosis with myelopathy.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld. 

This case pertains to a patient and review of medical necessity for an inpatient admission. The patient was admitted to outpatient ambulatory surgery for a C (cervical) 5-6 anterior cervical discectomy and fusion (ACDF) for cervical spondylosis with myelopathy, and intervertebral cervical disc disorder with myelopathy. Discectomy and fusion were done in the standard fashion. There was good decompression at the end of the case. There were no complications. Hemovac in place. The patient arrived at the post-anesthesia care unit (PACU). Anterior neck gauze dressing. The patient was alert and oriented x 3 without any neurological deficit noted. The provider documentation noted no indication of pain or discomfort. The patient's incision was clean, dry, and intact. No bleeding or hematoma was noted at incision site. 

The patient was medicated with Fentanyl 25 micrograms (mcg) intravenous (IV) on multiple occasions, 0.5 milligrams (mg) Dilaudid IV on multiple occasions, 0.4mg Dilaudid IV on multiple occasions, and 5 mg Oxycodone oral (PO). The dressing was clean, dry, and intact with Hemovac in place. Nursing noted the patient was afebrile with stable vital signs. No acute events occurred. There were no complaints of chest pain, shortness of breath, headache, or dizziness. There was no nausea or vomiting. Miami J collar was in place. Pain management consists of PO oxycodone providing adequate relief.  There was a note that the patient was not ready for discharge at that time. 

An appeal was sent for the denial of the inpatient admission. They noted the decision to admit was based on multiple considerations including the patient's diagnosis with inherent potential complications, the severity of illness at the time of evaluation, and an estimate of the risk to decompensate based on the clinical features of the case. 

The insurer sent a letter denying the inpatient admission. They noted the inpatient admission was not medically necessary. There were no problems with the procedure. They based their decision on Milliman Care Guidelines (MCG) guidelines for ambulatory exception criteria. The surgery was approved at the ambulatory level of care.

MCG notes the goal length of stay following an anterior cervical discectomy with fusion is a few hours to 1 day. A brief stay is 1-3 days. Extended stay beyond goal length of stay for primary condition may be needed until ALL of the following are present: Hemodynamic stability, Volume status acceptable (e.g., not dehydrated), Mental status at baseline, Hypoxemia absent, Tachypnea absent, Fistulas, tunneling, or infection absent or manageable at next level of care, Surgical management requiring inpatient care absent, Afebrile or temperature appropriate for next level of care, Pain absent or managed, Wound care needs manageable at next level of care, Drain absent or drain care manageable at next level of care, Wound hematoma or seroma absent or manageable at next level of care.

The review of clinical notes, guidelines, and literature found the need for an inpatient admission was not medically necessary for this patient. A 23-hour observation status would have been adequate to address the patient's pain needs. The record indicates that the patient received IV pain medication up until the day before discharge. There were no further notes to justify why the patient needed to be placed in the inpatient setting. The patient was alert and oriented, and dressing was dry and intact. The decision to deny the inpatient admission is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.