Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld in whole.

The patient is a male who was admitted to undergo an L4, L5, S1(vertebrae of the lumbar spine) laminectomy, discectomy on the left at L4-5(two lowest vertebrae of the lumbar spine), discectomy on the left at L5-S1(lumbosacral joint) and discectomy on the right at L5-S1(lumbosacral joint). There were no complications and blood loss was 50 cubic centimeter (cc). He was discharged from post-anesthesia care unit (PACU) and pain was controlled with current regime of intravenous Dilaudid. He was ordered intravenous (IV) Zofran, intermittent pneumatic compression, weight bearing as tolerated, intake/output, normal saline 100 milliliters per hour (ml/hr.) for 1000 milliliters, Ancef every eight hours x 3 doses that include pre-op and post-anesthesia care unit (PACU) dose, oral Tylenol, Flexeril, Pepcid, basic metabolic panel (BMP) every morning, physical therapy (PT)/occupational therapy (OT) evaluation/treat, oxycodone immediate release (IR). He remained neurologically intact and his pain was controlled with oral narcotics. He was evaluated by PT/OT and recommended discharge to home. He was ambulating, voiding and tolerating diet. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The requested health treatment of inpatient stay is not medically necessary. There was no hemodynamic, pulmonary, neurological or metabolic reason for acute level of care. The patient had no significant co-morbidities and was neurologically stable. His pain was controlled on oral medications outside PACU, was tolerating diet, voiding and ambulating. His care could have been provided at a lower level of care for routine monitoring. Therefore, the inpatient stay was not medically necessary.
This study reports a lower overall complication rate in the 30-day postoperative period following 1- and 2-level lumbar laminectomy performed in an outpatient versus inpatient setting. Significant risk factors for complications included body mass index (BMI) greater than (>) 30 kilograms per square meter (kg/m2), age greater than or equal to (>=) 55 years, a functional status of partially dependent, chronic obstructive pulmonary disease (COPD), chronic steroid use, American Society of Anesthesiologists (ASA) class 3 or 4, and operative time >90 minutes. (1)
We identified 85,769 patients, 41,149 classified as outpatient status and 44,620 as inpatient status. Between 2008 and 2016, the proportion of procedures performed on an outpatient basis increased from 24.1 to 56.74%. Overall, 27.3% of all patients were discharged on the day of surgery, representing 52.8% of outpatients and 3.8% of inpatients. Older age and longer duration of surgery predicted that patients were less likely to have same-day discharge. Patients with a primary diagnosis other than intervertebral disc disorder, Hispanic ethnic background, or an American Society of Anesthesiologists physical status classification of III were less likely to achieve same-day discharge. Patients under the care of orthopedic surgeons (as opposed to neurosurgeons) were more likely to be discharged on the day of surgery. We also found an association between sex and day of discharge, with female patients being less likely to be discharged on the day of surgery. (2)
In summary, the patient could have been treated at a lower level of care status.