Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tethered spinal cord
Treatment: Inpatient admission
The insurer denied coverage inpatient admission
The denial is upheld

The is a patient with a history of connective tissue disorder and tethered cord. He presented for an elective release of tethered cord-section filum terminale. Plastic surgery closed the wound. Minimal blood loss. He had no drains. A PCA (pain-controlled analgesia) was used to manage pain as well as IV (intravenous) fluids of sodium chloride at 75 ml (milliliter)/hour. He received IV Cefazolin every eight hours. He had a foley catheter and orders to lie flat for 24 hours. His pain was rated 7/10 and he was started on a PCA pump. In PACU (post anesthesia care unit) he reported pre-operative symptoms of primary nighttime painful penile erection, generalized body ache, occasional fatigue with hypertonic muscle, constipation, hypersensitivity and brain fog. Neurosurgery notes his pain is moderately controlled with PCA. He would be transferred to the floor. The plan is liquid diet until able to raise head of bed. Flat until tomorrow afternoon, pain control with PCA. He reported 7/10 pain and was given Tylenol. Later, he reported 6/10 pain. At 03:21 he reported 9/10 pain. At 06:03 his pain was rated 9/10. An interval history notes states no overnight events, pain not well controlled on PCA last night and transitioned to oral pain medications. They were better tolerated but still complains of incisional pain. Pre-op symptoms too early to see if any changes per patient. Exam is normal. Plan to elevate head of bed starting at 9 am until upright and observe for spinal headaches. Liquid diet until able to raise head of bed. Pain control as needed. He was seen by Physical Therapy , and he reported feeling dizzy while up in the chair. He had IV (intravenous) infusing. He had an alert, confused, sad/depressed affect. He was one assist and able to walk 20 feet. It was determined that skilled treatment is necessary. He has a shuffling gait, poor activity tolerance and slow cadence. It was determined that he needed skilled PT (physical therapy) and home with home care services versus outpatient therapy. A neurosurgery notes states postop day 2, no overnight events, pain better controlled, pre-op symptoms much improved per patient. Outpatient PT as needed. His dressings were changed. Pain interventions noted oxycodone 15 mg (milligrams) around the clock dosing utilized. He was discharged.
The patient did not have any severe postoperative findings that required inpatient level of care per guidelines.

The patient underwent an outpatient procedure and did not require inpatient level of care. He was monitored overnight due to the need to lie flat, and his pain was treated with a PCA that was transitioned to oral pain medication. His ASA (American Society Anesthesiology) score was not included by Anesthesia, and he had no significant co-morbidities. He had no severe bleeding, fever, abnormal lab values, delayed recovery from anesthesia, new neurological deficits, or infection. His stay could have been at an observational level for uncontrolled pain requiring change in medication dose or frequency and positional need per InterQual guidelines.

InterQual Acute Adult Criteria 2020 OBSERVATION, Both:

-	Post ambulatory surgery or procedure 

Pain uncontrolled and, Both:
-	Pain assessment
-	Requiring change in medication, dose, or frequency (1)

The insurer's denial of coverage for an inpatient is upheld. Medical Necessity is not substantiated.