Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Stenosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient who was admitted for lumbar laminectomies for stenosis. The patient underwent uncomplicated L (lumbar) 2-S (sacral) 1 laminectomies. A Hemovac drain was left in place. The patient was on intravenous (IV) antibiotics while the drain was in place.  Once the drain was removed, the claimant was discharged to home.

The Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care Lumbar Laminectomy Guidelines note inpatient stay may be needed for infection, patient with infectious basis for surgery may require longer monitoring on parenteral antibiotics and confirmation of culture results, fracture or neoplasm or active comorbid illness (e.g., cardiovascular or pulmonary disease). 

The patient was admitted for lumbar laminectomies for stenosis. The patient underwent an uncomplicated L2-S1 laminectomies. Given the required management of the Hemovac drain and the intravenous antibiotic maintenance required to support the Hemovac drain, the inpatient admission would be considered medically necessary for this patient. The required level of care would exceed care available on observation status.

"An interprofessional team provides a holistic and integrated approach in the care of suction drain. The role of the nurse and family must be determined. If the patient is to be discharged with drain, educate the caretaker who can monitor and care of the drain. The major complication associated with drain is accidental slippage from the wound, and the patient has to be evaluated immediately. The fluid measurement and maintaining the record are essential to time the removal of the drain. The care of the drain insertion site has to be educated to all team members. Inexpensive and straightforward antiseptic intervention at the drain insertion site reduces bacterial colonization of drains. Effective prevention for seroma formation in the postoperative period is with the use of the closed-suction drain. The suction drain should be kept until their output volume was minimal and maintain a high-pressure gradient" (Ramesh et al., 2023).

"Posterior spinal decompression is one of the most common surgical procedures to release neural structures when nonoperative treatment has failed and is usually the procedure performed for degenerative conditions such as spinal stenosis, especially in middle-aged and elderly patients. It is one of the most common spinal surgeries among cohorts more than 65 years of age. The classical laminectomy constitutes a central, facet joint sparing laminectomy. The spinous process and the lamina are removed limited laterally to the medial part of facet joints. There was no benefit in preserving the midline structures. The central canal, the lateral recesses, and the neural foramina need to be decompressed for good clinical recovery and prevention of failed back surgery syndrome" (Estefan et al., 2023). 

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.