Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical spondylosis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was admitted to undergo an elective anterior cervical discectomy and fusion at cervical (C) 5-6 and C6-7 for cervical spondylosis with myelopathy/radiculopathy.  The patient has a history of hypertension and diabetes mellitus managed on oral medication.
The operative report noted minimal blood loss and no complications. The patient had an American Society of Anesthesiologists (ASA) score of 2 which carries a low risk of complications. He was in the post-anesthesia care unit (PACU). Floor orders included blood glucose monitoring, standard vital signs, medications, lab studies, physical therapy (PT) / occupational therapy (OT) evaluations. He received two doses of Percocet  and pending was noted the next day.
A hospital course by neurosurgery notes that postoperatively he reported improvement in left thumb numbness. His exam was normal. He had no overnight events. He had no uncontrolled pain. He had an uncomplicated postoperative course and was discharged home. The inpatient stay is under review for medical necessity.

No. The inpatient stay was not medically necessary.
The patient does not meet inpatient criteria for the surgery performed per Milliman Care Guidelines (MCG) guidelines.
Ambulatory: 1-level or 2-level fusion at or below C3 in nonelderly patients (younger than 65 years) without myelopathy and without need for extended (ie, more than 24 hours) postoperative observation Inpatient: Elderly patients (65 years or older), multilevel (3 or more) fusion, patients requiring extended postoperative observation (eg, unstable comorbidities), or procedure on C1-C2 may require overnight stay. (1)
The patient did not have uncontrolled diabetes, ASA score 3 or above, perioperative complications, unstable vital signs, uncontrolled pain, uncontrolled bleeding or severe neurological deficits. His care could have been provided at a lower level for a two level anterior cervical discectomy and fusion (ACDF) to monitor overnight for safety. 
We found that for patients who have undergone ACDF, the prognostic factors that contribute to increased post-operative hospital length of stay (LOS) are older age, female gender, and three types of complications-cardiac, urinary, and pulmonary. (2)
Outpatient ACDF carries the feared complication of delayed neck hematoma, and there maybe an optimal postoperative observation period to prevent any delayed complications. Lied et al. studied the timing in detecting a postoperative complication after ACDF. Thirty-seven patients (9%) among 390 consecutive surgeries experienced any surgical complication. When stratified by the timing of presentation-immediate (within 6 hours), early (6-72 hours), and late (greater than 72 hours)-all 5 patients (1.2%) who developed a neck hematoma had been diagnosed and undergone evacuation within 6 hours."(3) Arshi, et al reports, "Outpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks."(3)