Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck/back pain. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

According to the documentation submitted, this is an adult with a history of hypertension, chronic cough, and migraines. The patient presented to the hospital for an anterior cervical diskectomy and fusion C (cervical) 4-C6 under general anesthesia. The patient was admitted to Neurosurgery. A Jackson-Pratt (JP) drain was placed. The patient was extubated and routine monitoring was done. The patient was given oral (PO) oxycodone. The patient was evaluated by physical therapy and occupational therapy (PT & OT). The JP drain was removed before discharge. 
The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient had a procedure on the bones in the neck. There was no severe active disease warranting an inpatient admission. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Ambulatory Surgery Exception Criteria. 
"Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined" (3). 
"Can anterior cervical diskectomy/fusions (ACDF) be safely performed in ambulatory surgical centers (ASC) (ASC-discharges 4-7.5 hrs. postoperatively) adhering to "stringent exclusion criteria". As outlined in many studies, these exclusion criteria included; avoiding elevated body mass index (BMI) (i.e. obesity/ morbid obesity, non-routine "morphology"), major comorbidities, age > 65, American Society of Anesthesiology (ASA) scores > II, and as raised by Gennari et al., multilevel ACDF?[1,4-6] Presently, the majority of ACDF are still performed in hospital-based outpatient surgical centers (HBSC: utilizing 23-hour stays), or as inpatients.[1,4-6,8,9] Here, we analyzed outcomes of 1-level vs. multilevel ACDF performed in ASC, focusing on immediate postoperative hospital transfer rates, and up to 30 and 90 day postoperative emergency department (ED) visits, readmissions, and reoperations.[1,2,4-10] Again, our main question was whether ACDF could be safely performed in ASC. Furthermore, isn't it common sense that "less (surgery) should be less (morbidity)", that 1-level ACDF should involve "less risk" vs. multilevel procedures performed in ASC" (1). 
"In an effort to improve efficiency of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed and rarely requires overnight stays in the hospital, supporting its migration to the ASC. Recent analyses have called into question the safety of outpatient ACDF, potentially slowing its adoption. ASC-ACDF studies have largely been limited to small series, precluding an accurate assessment of safety" (2). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.