Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Stenosis, Urinary Retention

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was overturned.   

This is a male patient who presented to the hospital for elective bilateral L (lumbar) 3-4 and L4-5 laminotomies with METRx (minimally invasive microdiscectomy). The patient's diagnosis was spinal stenosis with neurogenic claudication. The patient had preoperative bladder urgency with some incontinence. The plan was to mobilize and control his pain. The patient reported his pain severity was 10/10 pain and oxycodone provided minimal relief; intravenous (IV) morphine was given for this patient's pain. The patient was monitored for urinary retention and pain control. An attending note stated that they needed a post residual void recorded for the patient. The patient was seen by occupational therapy and determined that he was independent with activities of daily living and functional transfers. It was reported that the patient was unable to void. The plan stated spine checks every four hours, pain control, monitor for urinary retention, out of bed, mobilize, regular diet, and urology consult if he failed to void; a Foley catheter was placed by Urology. The patient reported severe near constant burning pain in the legs; mild improvement noted with oxycodone and IV morphine. Urology's plan stated to keep Foley until clinically optimized, reduce narcotics, ambulate as able, Flomax, encourage bowel movements and try a voiding trial before discharge home. A Nursing notes stated that the patient was very anxious and his pain was rated 10 out 10, in severity and that he had called out every 15 minutes for pain medication. He received Zofran for his episodes of nausea. The patient left against medical advice.

Postoperative urinary retention (POUR) is a very common postoperative complication of all surgeries (5% [percent]-70%) that may lead to complications such as urinary tract infection (UTI), bladder over-distension, autonomic dysregulation, and increased postoperative length of stay (LOS). (1)

"Ketamine is helpful for attenuation of postoperative pain by its direct analgesic effects and preventing the nociceptive pathway sensitization in the central nervous system.  Being a NMDA [N-methyl-D-aspartate] receptor antagonist, it is believed to reduce or reverse opioid tolerance in patients who are chronic opioid users. The suggested contribution of NMDA receptors in opioid tolerance and development of hyperalgesia supports the effectiveness of subanesthetic doses of ketamine in alleviating postsurgical pain. Studies on patients undergoing spinal surgeries have not yielded any definitive results. [43] Loftus et al. had demonstrated the reduction in postoperative narcotic demand following intraoperative ketamine administration without any side effects. [4] Subramaniam et al. however contradict this view through their investigation that failed to demonstrate any improvement in analgesia following intraoperative and postoperative infusions. [44] Dysphoria, sedation, diplopia, salivation, nausea, and hallucination restrict the extensive utilization of this drug in pain management practice." (2)

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

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