Appeal type: Medical necessity
Decision: Overturned

Diagnosis: lumbosacral neuritis, lumbago-sciatica, spinal stenosis, lumbar region lumbosacral stenosis, left lumbosacral radiculopathy,

Treatment: acute inpatient services

The insurer denied coverage for acute inpatient services. The denial was reversed.

This patient is a male patient with an in-hospital patient stay. There was documentation of a past medical history significant for attention deficit hyperactivity disorder, anxiety, gastroesophageal reflux disease, Gilbert's syndrome, hiatal hernia, hyponatremia and male pattern baldness. The patient was admitted to the hospital for surgical intervention, L5-S1 discectomy/laminectomy with fusion of the lumbar done posteriorly, at one level with instrumentation at L5-S1. There was documentation that the surgery was performed without complications. A post-anesthesia evaluation revealed that the patient participated, was awake and alert, pain management was adequate, air patency was patent, respiratory status was acceptable and postop hydration was acceptable and the patient was transferred to the surgical floor.

On the second postoperative day, the physician documented that the patient and family were at the bedside, the patient was doing well and oral fluids were encouraged. The patient was being transitioned to oral (p.o.) Dilaudid and encouraged to wean from patient controlled analgesia (PCA) use. The patient verbalized understanding. There was documentation that on postop day two the physical therapist's assessment was that the patient tolerated the treatment well, the patient reported left lower extremity numbness and tingling throughout the session that was like symptoms he had prior to surgery. The patient was able to increase ambulation distance significantly with the session and perform stair negotiation.  However, the patient required verbal cues for sequencing during stair negotiation. 

The issue relates to the benefit from one additional physical therapy session to ensure safety and independence prior to discharge from his inpatient hospital stay. The additional physical therapy session did occur and the patient was discharged from the facility to home.
  
The Milliman Care Guidelines (MCG) recommend up to a two-day inpatient hospital stay after lumbar spinal fusion. However, exceptions to the guidelines include a new onset neurologic deficit, and adequate ambulation. In the clinical records submitted for review, on post-op day two, there was documentation by the physical therapist and the surgeon of new onset left lower extremity numbness and tingling at the bedside with surgeon and throughout the physical therapy session with the therapist of left lower extremity numbness and tingling that was like symptoms the patient had prior to surgery. The physical therapist recommended an additional physical therapy session the following day to address the deficit and due to the patient requiring verbal cues for sequencing during stair negotiation, which is warranted for the patient's safety and function at home following discharge from the hospital. 

Therefore, the acute inpatient services rendered for lumbar fusion was considered medically necessary for this patient.  The health plan did not act reasonably and with sound medical judgment, in the best interest of the patient. 

The carrier's denial of coverage for the acute inpatient services rendered for lumbar fusion is reversed. The medical necessity is substantiated.