Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical Myeloradiculopathy.
Treatment: full hospital admission.
The insurer denied coverage for full hospital admission.
The denial is upheld.

This is the case of an adult female patient who presented for an elective outpatient anterior cervical discectomy and fusion (ACDF) at cervical spine level, C (cervical) 5-6 for a history of cervical disc herniation with cervical myeloradiculopathy on. Medical history includes gastroesophageal reflux disease (GERD), kidney stones and hyperlipidemia. The American Society of Anesthesiology (ASA) score was 2. There were no complications during surgery and a drain was placed. Her disposition stated that she required post-operative overnight evaluation and monitoring for airway or swallowing complications and would stay overnight as an outpatient. Anticipate discharge tomorrow if stable. Post-operatively she developed chest pain with tachycardia in the post anesthesia care unit (PACU). Orthopedics ordered stat creatine kinase myocardial band (CKMB) and Troponin, continue intravenous fluids (IVFs). Laboratory studies show calcium 8.3 and creatinine 0.46. She was using a Dilaudid patient-controlled analgesia (PCA) pump. At 0930 an order for inpatient admission was written. 

Note by Orthopedics stated chest pain overnight with tachycardia following Dilaudid. Her electrocardiogram (EKG) and troponin were negative and switched pain medication to oral oxycodone. This morning she felt well with resolution of chest pain. Her Blake drain was in place and drained 5 cubic centimeters (cc) over eight hours and 13.5 cc over 24 hours. Her exam noted 5-/5 weakness in the left tricep and wrist extension. The plan was to discontinue foley, physical therapy (PT), oral pain control, remove drain at noon, follow up labs in the morning and discharge home today pending pain control. 

She reported subjective shortness of breath with oxygen (O2) saturation 98% (percent) room air and in no distress. Cardiology consulted and repeat troponin today. She reported dizziness when up with occupational therapy (OT) but not anymore. Her pain was controlled. She received intravenous (IV) Decadron every six hours. Heart rate varied 92-103 beats per minute. A Cardiology note stated that they doubted chest pain is pathologic given prolonged duration, no EKG changes and negative troponin, normal saturations. The patient is chronically tachycardic, please check thyroid stimulating hormone (TSH). No contraindication to discharge. 

Orthopedics stated that she felt much better than yesterday, pain controlled and ambulated 200 feet yesterday. Her Blake drain was in place and drained 2/14 cc over 8 hours and was removed. She was discharged.

There was no indication for inpatient admission according to the Milliman Care Guidelines (MCG) for Cervical Fusion Anterior.

The patient's care could have been provided at an observational level for care and monitoring and discharged. She had no significant co-morbidities. She was evaluated by Cardiology and recommended discharge. Her drain was to be removed. She was up walking 200 feet with therapy. Her pain was well controlled on oral medications. She had no hemodynamic instability, severe neurological deficits, no uncontrolled pain, or bleeding. Anterior cervical discectomy and fusion is considered an outpatient/observational surgery according to general standards of practice for patients that have no significant co-morbidities and no severe postoperative findings.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.