Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cervical Fracture.
Treatment:  Inpatient Admission.

The insurer denied the inpatient admission.  The denial was upheld. 

This is a young female patient who was transferred from another medical facility with C6, C7 fracture and a sternal fracture.  It was reported that she was in a roll over motor vehicle accident; the patient was unrestrained.  The patient complained of neck pain with numbness and tingling to the left arm/hand; her Glasgow Coma Score was 15.  A neurological exam was performed that showed decreased left hand strength.  The patient's heartrate was bradycardic.  She had an episode of vomiting and was treated with intravenous (IV) morphine, Zofran, Decadron, Reglan and Ativan.  Trauma surgery/Orthopedic services were consulted.  A computed tomography (CT) head, CT cervical spine, CT angiography, magnetic resonance imaging (MRI) cervical and thoracic spine were performed.  The patient's CT spine showed an acute fracture that involved the left C6 lamina and inferior articular process and extended into the left-sided facet, which was markedly subluxed, associated with C6-7 spondylolisthesis.  The patient's diagnoses listed nausea and vomiting, spondylolisthesis, contusion of lung, sternal fracture and closed fracture of cervical spine.  The patient was taken to the Operating Room (OR) where she underwent open reduction and internal fixation of C6-7 fracture dislocation, anterior cervical discectomy, decompression and subsequent fusion C6-7, placement of spacer and plate with screws.  The patient experienced no post-operative complications.  The patient was discharged home after a period of medical stability with physical therapy/occupational therapy (PT/OT) rehabilitation in place.  

Based on the review of the medical record and literature, inpatient admission was not medically necessary.  The patient's services could have been provided at a lower level of care.  The patient had no hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient admission.  However, since the patient required overnight monitoring to allow for neurological monitoring after her surgery, pain control, and drain management, Ambulatory Surgery level of care would have been appropriate.   According to literature, observation is intended to be for one midnight to assess presenting signs and symptoms as the patient progresses toward improvement, stabilization, or decline.  A second midnight is allowed with documentation that supports the continued need for re-assessment to determine if discharge or inpatient admission is appropriate (1).

The MCG Cervical Fusion Operative Status Criteria states: Ambulatory: 1-level or 2-level fusion at or below C3 in non-elderly patients (younger than 65 years) without myelopathy and without need for extended (i.e., more than 24 hours) postoperative observation.  Extended stay Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days).  Extended stay beyond goal length of stay may be needed for: Severe deficit or injury; Patient with significant neurologic compromise, cervical injury, or multiple injuries will require longer acute care and recovery times; Stay extension varies depending on injury (2).

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the hospital stay at the inpatient level of care should be upheld.  The medical necessity is not substantiated.