Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal stenosis, Radiculopathy, Neurogenic claudication.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. The denial is overturned. 

This is a male patient with a medical history of S1 spinal stenosis, radiculopathy, neurogenic claudication, prior cervical spine surgery, hypertension, hyperlipidemia, diabetes, carotid stenosis, and hyponatremia. The patient presented to the hospital for a planned outpatient surgery and underwent L2 to S1 laminectomies and foraminotomies with application and removal of Gardner-Wells tongs with 2 subfascial hemovacs and 1 superficial Blake drain with bilateral paraspinal muscle flap and wound closure by Plastic Surgery. The surgeon stated that the surgery required significant extensive partial resection of the lamina and retraction of the dural sac and nerve in order to safely perform the decompression. This increased this patient's risk of hematoma, weakness or swelling. The additional bone removal when compared to a smaller procedure done at an ambulatory facility would result in increased postoperative pain, and would require intravenous pain medication. 

Based on the review of the medical record and literature, the inpatient admission was medically necessary for pain control, drain monitoring and physical rehabilitation. The patient was seen by nephrology for chronic hyponatremia. The orthopedic plan was for physical therapy (PT), weight bearing as tolerated, brace when out of bed, repeat sodium, fluid restriction, transition to oral medication once out of bed, and discharge pending PT evaluation. On the day of discharge, orthopedic service stated that the patient was disoriented overnight but alert that morning. The patient's pain was controlled and the patient was tolerating diet. This patient's comorbidities, multilevel extensive decompression and complex wound closure with drains do not appear to be considered in the Insurer's decision to deny the inpatient status. As per Milliman Care Guidelines (MCG), lumbar laminectomy is considered ambulatory for patients without active comorbidities undergoing minimally invasive or uncomplicated single level elective lumbar laminectomy. Inpatient care is for patients who have comorbidities that require prolonged inpatient monitoring, or whose surgery is non-elective or otherwise complex. An extended stay is for intra/extra-spinal hemorrhage.

In this case, the patient meets the criteria for inpatient admission. The patient had preoperative urinary retention, was status post carotid surgery, diabetic and had an American Society of Anesthesiology (ASA) score of 3. The patient would be considered a high risk for readmission due to his urinary retention and wound management with observing for healing at spine with hemovac drains per guidelines. As per literature review, this patient was also at a higher level of risk for adverse effects due to his cardiac and diabetic comorbidities, 5-level decompression procedure, extensive wound closure and the required use of 3 drains. Literature review indicates that patients who require multilevel lumbar procedures and/or have a preoperative coagulopathy are at a significantly higher risk for developing a postoperative epidural hematoma. Thus, this patient's care could not have been provided at a lower level of care, and the inpatient stay was medically necessary for this patient.

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

The medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.