Appeal type: Medical necessity
Decision: Overturned

Diagnosis: radiculopathy.

Treatment is inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This adult patient was seen as an outpatient for back pain and radiculopathy in the sacral one (S1) distribution. The magnetic resonance imaging (MRI) showed a herniated disc with contact of the left S1 nerve root. The plan was for the patient to undergo a microdiscectomy.

The claimant was discharged after undergoing a lumbar five to sacral one (L5-S1) microdiscectomy. The procedure was complicated by a dural tear that was primarily repaired in the operating room (OR) and needed post-operative monitoring. The patient was to remain flat in bed. He worked with physical therapy (PT) before discharge. 

While considering the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, given that the claimant had an intra-operative complication of a dural tear with subsequent repair. It was appropriate for an inpatient stay post-operatively to follow the dural tear protocol including a period of lying flat. The patient could not travel or sit upright. This was to make sure the repair held and that the patient did not need to return to surgery.

"Dural tears are not uncommon complications in spine surgery, with an incidence varying from 1.6% (percent) to 10%. Although primary repair of a dural tear is generally satisfactory, persistent CSF (cerebral spinal fluid) leakage resulting from incomplete closure can lead to complications such as postural headache, nausea, vomiting, dural cutaneous fistula formation, meningitis and even intracranial hemorrhage. Moreover, treating these complications often requires prolonged bed rest, which is associated with subsequent complications including pneumonia, deep venous thrombosis and pulmonary embolism" (Choi, E. H., et al. 2021). 

"Purpose: A dural tear is a common iatrogenic complication of spinal surgery associated with a several post-operative adverse events. Despite their common occurrence, guidelines on how best to repair the defect remain unclear. This study uses five post-operative outcomes to the compare repair methods used to treat 106 dural tears to determine which method is clinically favourable.

Methods: Data was retrospectively collected from online databases. 106 tears were identified and grouped per repair method. MANOVA (Multivariate analysis of variance) was used to compare the following five outcomes: Length of stay, numbers of further admissions or revision surgeries, length of additional admissions, post-operative infection rate and dural tear associated neurological symptoms. Sub-analysis was conducted on patient demographics, primary vs (versus) non-primary closure and type of patch. Minimal clinically important difference (MCID) was calculated via the Delphi procedure.

Results: Age had a significant impact on patient outcomes and BMI (body mass index) displayed positive correlation with three-fifth of the predefined outcome measures. No significant difference was observed between repair groups; however, primary closure of the patch achieved an MCID percentage improvement with regards to length of original stay, rate of additional admissions/surgeries and post-operative infection rate. Artificial over autologous patches resulted in shorter hospital stays, fewer readmissions, infections and neurological symptoms.

Conclusion: This study reports the primary closure dural patch as the most efficient repair method with regards to the five reported outcomes. This study provides limited evidence in favor of artificial over autologous patches and recommends that dural patches be used in conjunction with primary closure.

Level of evidence i: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding" (Taylor, C., et al. 2022). 

"Discussion: This protocol provided effective management of dural tears in lumbar surgery, with no application problems. We suggest a number of improvements: the use of the Valsalva maneuver to test the suturing, a stand-up test for the patient, and a systematic late MRI (magnetic resonance imaging) to detect meningoceles. There is no reason to change the other points in the protocol: suturing, controlled drainage for watertight wounds, no drainage for the non-watertight wounds, antibiotics, and supine bed rest position 48h (hours)" (Wolff, S., et al. 2012). 

"Sustaining a dural tear while undergoing posterior lumbar spinal decompression and/or fusion for degenerative pathology significantly increased the risk of complications and increased length of stay, risk of readmission, and overall, 90-day hospital cost. Dural tears specifically increased the risk of a VTE (Venous thromboembolism) complication by 1.46 times and meningitis by six times; these are important complications to have a high degree of suspicion for in the setting of durotomy, as they can lead to significant morbidity for the patient" (Alluri, R., et al. 2020).                                                         

Based on the above, the insurer's denial must be overturned. 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 inpatient admission is substantiated.