Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Neck Problem/Pain
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a male with a history of neck pain and cervical radiculopathy. A history of obstructive sleep apnea is noted in the medical records. According to the indications section of the operative note, imaging had revealed significant stenosis and neural compression at cervical (C) 5-6 and C6-7, and he was offered surgery. The patient underwent and ACDF (anterior cervical discectomy and fusion) at C5-6 and C6-7. The operative note does describe difficulty in exposing C6-7 due to an elevated clavicle as well as a large osteophyte that limited esophageal mobilization, requiring the anterior plate to be placed more on the left side, where the exposure had been obtained. The surgery was otherwise without recorded incidence. A Foley catheter had been placed preoperatively and 2 deep drains were placed at the time of surgery. The patient was then admitted under an inpatient status to the hospital.

The patient did well after surgery. The Foley catheter was removed the morning after surgery and drain output was noted to be minimal. He was able to take oral nutrition and medications and was cleared by physical therapy (PT) for safe ambulation. The drains were removed, and the patient was later discharged home.

There is a notation by the surgeon that due to the extensive dissection above and beyond what is typical for this procedure, the case was not appropriate for an ambulatory setting, and therefore there was a need for an inpatient admission. The health plan has denied the inpatient stay  as being not medically necessary. That is the question for this review.

The records provided support upholding, in whole, the health plan's determination of medical necessity.

No, there is no support in the documentation provided or in the medical literature for the medical necessity of an inpatient stay for this patient undergoing an elective ACDF procedure. It is very common to admit ACDF patients to an observation level of care in order to monitor them overnight, as the complications of respiratory distress from either tissue swelling or a postoperative hematoma usually occur the night of surgery and frequently require emergent attention. Particularly given the difficult dissection and large osteophytes encountered, it would have been inappropriate to have performed this surgery on a purely outpatient basis had that been the initial plan. However, the patient could have been admitted under an observation status with the plan to keep him at least for an overnight stay.
 
In addition, should any intraoperative or postoperative complications occur, then the patient can always be reclassified as an inpatient as needed.

In selective healthy patients, this procedure is frequently carried out in a completely outpatient setting, which as noted above would not have been appropriate for this patient given the history of sleep apnea and the difficulty encountered in the exposure during surgery.

The Guidelines provided for review support this standard clinical practice noting that the goal length of stay for most patients is "Ambulatory or 1 day postoperative" which is supported in the literature.