Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar herniated disc with radiculopathy 

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with a past medical history of hypertension. She underwent a planned procedure of a L4-5 laminectomy and discectomy for a lumbar herniated disc with radiculopathy without complication. Her presurgical history and physical noted her heart rate was 60 and blood pressure of 110/77. She did not have neurological deficits on exam. Her ASA score was a 2. She used a cane for assistance prior to surgery. Her clearance for surgery noted her to be a low perioperative cardiovascular risk for complications. Preoperative laboratory studies and EKG were within normal limits. PACU notes she was tachypneic and on supplemental oxygen. She had episodes of bradycardia and low blood pressure. Post-op neurosurgery notes indicated that her neuro was at baseline. The patient had no drains, had PT eval, follow up labs in the morning, advance diet as tolerated, pain control as needed, SCDs, incentive spirometer, bowel regimen. She received intravenous Tylenol x1 and Decadron x 4 doses, IV Ancef x3, oral Valium every eight hours, Colace, gabapentin, oxycodone x1, lactated ringers at 75 ml/hr. She was admitted to inpatient level of care. She was cleared from inpatient skilled physical therapy program. Nurse notes indicated no new changes to status, tolerating diet, voiding adequately, cleared for discharge by Neurosurgery and was discharged.

Lumbar laminectomy with or without discectomy remains the most common spine operation performed in the United States and was one of the earliest procedures to be successfully transitioned to the outpatient setting (Table 1). Several groups have reported clinical series describing favorable outcomes. Helseth, et al. reported on a series of 1073 consecutive patients undergoing lumbar procedures at a freestanding neurosurgical clinic with a successful discharge rate of 99.8% on the day of surgery. No patients died within 30 days, and the 90-day readmission rate was 1.5%. Nine patients (0.6%) suffered a postoperative hematoma, which was recognized and evacuated postoperatively, and these patients were subsequently discharged the same day. Pugely and colleagues performed a propensity score-matched analysis of 4310 lumbar discectomy cases in the American College of Surgeons database. Interestingly, in the matched cohort, the inpatient group had a significantly higher rate of complications (OR 1.521) even after adjusting for potential confounders. Moreover, an advanced age, diabetes, and operative times longer than 150 minutes were independent predictors of a postoperative complication. All data taken together, lumbar decompression has the strongest evidence for safety in the outpatient setting. (1)

The health plan acted reasonably with sound medical judgment. She did not have any significant findings in vital signs out of PACU. She did not require frequent neurochecks and her exams were normal. Her pain was controlled with oral medication. Her surgery was without complications. She was ambulating, voiding and tolerating a diet in the morning after surgery. Care could have been safely and effectively performed at an observational level.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.