Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Surgery.
Treatment: Full Hospital Admission.

The insurer denied Full Hospital Admission.  The denial is overturned.

The patient is a female with no significant medical history, who presented to undergo an elective procedure. An operative report noted a left sided anterior annulectomy at cervical (C)4-5 and C5-6, C5 corpectomy, anterior cervical vertebrectomy C5 and partial vertebrectomies C4 and C6 with 33-50% removal, placement of polyetheretherketone (PEEK) corpectomy cage C4-C6, plate and screws. A Jackson-Pratt drain was placed. Her surgery was 3 hours and 15 minutes. Estimated blood loss 150 cubic centimeters (cc). There were no complications. She had an American Society of Anesthesiologists (ASA) score of II. Neuro checks were ordered every 15 minutes x 4, every 30 minutes x 2, hourly x 2 and then every four hours for 24 hours. She had a normal neurological exam.
Postoperatively she had difficulty maintaining pain control and pain management was consulted with an additional dose of oxycodone 5 milligrams (mg) as needed for breakthrough, Flexeril three times a day, and Tylenol 1000 mg every eight hours as needed was ordered.

She remained neurologically and hemodynamically stable. Her pain improved. Her Jackson-Pratt (JP) drain was removed. Physical therapy (PT) recommended ongoing treatment. Hemoglobin and hematocrit (H&H) 10.5 and 32.2. She was discharged home with follow up.

The full hospital admission was medically necessary for this patient. She underwent a multilevel fusion with a C5 corpectomy and vertebrectomy, and partial vertebrectomies C4 and C6 with an increased risk for injury given the complexity of the surgery.
A corpectomy is a more extensive procedure than a discectomy, so the risks are statistically greater, especially with respect to neurologic issues, bone grafting and bleeding. The risk that spine surgeons worry about the most is compromise of the spinal cord that can lead to complete or partial quadriplegia. Bear in mind that corpectomy surgeries are most often undertaken in circumstances of significant spinal cord problems, which place the cord at greater risk for problems during surgery, independent of the skill and finesse with which the procedure is performed. To help manage this risk, the spinal cord function is often monitored during surgery by Somatosensory Evoked Potentials (SSEPs). SSEPs generate a small electrical impulse in the arms/legs, measure the corresponding response in the brain, and record the length of time it takes the signal to get to the brain. Any marked slowing in the length of time may indicate compromise of the spinal cord. There is also a slight risk that while removing the vertebral body, the vertebral artery that runs on the side of the spine may be injured, which can lead to a cerebrovascular accident (stroke) and/or life-threatening bleeding. This particular risk will be more significant in certain instances of tumor removal or vertebral infections. (1)

The patient underwent a complex surgery that included a corpectomy, vertebrectomy with placement of cages and fusion. She was considered at high risk for significant morbidity. A full hospital admission was medically necessary.