Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical Myelopathy

Treatment: Full hospital admission 

The insurer denied coverage for a full hospital admission

The denial is overturned.

This patient has a history of hypertension, cervical myelopathy, and ossification of the posterior longitudinal ligament (OPLL) with cord compression who was admitted for an anterior cervical discectomy and fusion (ACDF) with partial corpectomy. Her American Society of Anesthesiologists (ASA) score was 3. A hemovac drain was placed. The operative note stated that extensive neck dissection and bone resection was above and beyond what was typically performed in the ambulatory surgery setting. There was concern for progressive airway swelling and development of a compressing hematoma given her pathology. Post Anesthesia Care Unit (PACU) noted ephedrine and glyco were given for bradycardia for a heart rate in the 30s beats per minute. They had difficulty obtaining a blood pressure. Her heart rate increased within the 50 beats per minute range and blood pressures in the 90s/50s range. After surgery her pain was controlled with fentanyl and Dilaudid patient-controlled analgesia (PCA). Her bilateral hand numbness had improved. The treatment plan included pain management, 2 doses of Ancef, deep vein thrombosis prophylaxis, physical therapy, monitoring of urinary catheter output, bloodwork, a neurovascular exam and administration of her current medications. The following day her hemovac drain was removed. Her incisional pain was well controlled. Her dressing was clean, dry and intact. Vital signs were stable Her urinary catheter was removed. She transitioned to oral medication. She was seen by Physical Therapy/ Occupational Therapy. She was discharged home with home health.  

Per InterQual: Patient specific clinical factors that may support management of an outpatient procedure in the inpatient setting include:
1)  Elderly patients
2)  Substance use with high risk for withdrawal
3)  ASA Score (greater than or equal to) >= 3
4)  Hypertension 
5)  Coronary artery disease 
6)  Chronic obstructive pulmonary disease 
7)  Thromboembolic event within the last 3 months (cerebrovascular accident,
   transient ischemic attack)
8)  End stage renal disease 
9)  Heart failure (1)

Milliman Care Guidelines for Cervical Fusion:

Inpatient: 
1)  Elderly patients multilevel (3 or more) fusion, patients requiring extended postoperative observation (eg, unstable comorbidities), or procedure on cervical vertebrae 1 and 2 may require overnight stay.

Extended stay beyond goal length of stay may be needed for (1)(24)(56)(62)(63)(64):
1)  Severe deficit or injury (30)(65)
2)  Patient with significant neurologic compromise, cervical injury, or multiple injuries will require longer acute care and recovery times. (2)

Outpatient discharge after anterior cervical discectomy and fusion (ACDF) is a viable treatment option with a reasonable safety profile and decreased costs relative to inpatient admission. Appropriate patient selection is key, and the standard of care nationally for the comorbid patient remains inpatient admission. The economic trends and epidemiologic data presented here should be useful for making health policy decisions, and for future researchers in this area. (3)

The insurance company did not consider her age and the significance of her pathology that would be cause for concern of complications.

Given her age, hypertension, ASA score, the extensiveness of her surgery with corpectomy and extensive dissection required with increased risk for airway swelling and hematoma, PACU bradycardia to 30s and difficulty obtaining a blood pressure, an inpatient stay was medically necessary to ensure the safety of the patient per guidelines and general standards of care. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.