Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall, Dislodged Hardware.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department status post six weeks thoracic (T) 11-lumbar (L) 3 surgery after a fall with the T11 rod being dislodged. Per appeal, he was scheduled for a revision. He was seen for a presurgical visit and the patient disclosed that he was going through heroin withdraw. He indicated that he was heroin free and began using again which caused multiple falls. Heroin use was unknown to neurosurgery until this date. He was directed to the emergency department (ED) for further evaluation of his fall and back injury and to evaluate heroin withdraw complications. He met Milliman Care Guidelines (MCG) care guidelines 25th edition for Substance-Related Disorders, Adult M-595 for withdraw signs and services not feasible at lower level of care and MCG care guidelines under 25th edition Lumbar Fusion S-820 for spinal repair with fusion for lumbar dislocation. The patient requested assisted detoxification prior to scheduled surgery.
A denial stated that the inpatient stay was not medically necessary as he had no signs of serious withdrawal, no history of complicated withdrawals before, or any other medical issues that would need them to be in the hospital for this. He was not in medical danger.
An appeal stated that the patient's situation included a relapse of heroin use after his first surgery, current heroin use with a pending surgery, anticipated severe acute pain following spinal surgery which placed him at high risk for multiple complications including death with unmanaged heroin withdrawal. Inpatient admission should be considered medically necessary given his clinical presentation, medical history, hospital course and risk for adverse events and outcomes.
He presented to the emergency department and reported that he was advised by his spinal surgeon to be admitted for detoxification treatment prior to his second spine surgery. He reported being on heroin recently and withdrawing. His doctor wanted to make sure that he was totally clean before surgery. He was status post lumbar fusion six weeks ago and slipped and fell breaking his hardware. He reported he had not used for a couple days. He was on suboxone. He denied numbness or weakness and denied symptoms of withdrawal or pain. His exam was normal. The plan was to admit, spine watch assessment every two hours, intake and output every four hours, lab work, 1000 milliliter (ml) normal saline intravenous (IV) bolus, oral opiates as needed, vital signs every four hours, Flexeril as needed, gabapentin three times a day, heparin subcutaneous, Atarax as needed, operating room (OR) planning, Toxicology consult for suboxone. His heart rate was tachycardic at 122, likely due to withdrawal. He had a diagnosis of heroin dependence and postoperative complication.
He was seen by toxicology for a consult. He smokes heroin and relapsed for five weeks recently with restarting suboxone five days ago and on 16 milligrams (mg) daily. He was taking oxycodone 10 mg. The plan was to reduce suboxone to 8 mg prior to major surgery, recommend Acute Pain Services (APS) consult, continue to follow.
Neurosurgery reported a normal exam and denies pain. The plan for was for the OR tomorrow, every 2 hour spine checks, continue detox. Toxicology reported he was doing well on suboxone 8 mg daily, denied withdrawal symptoms, had not needed as needed opioids.
He underwent revision of the previous T11 to L3 fusion with reduction of kyphotic deformity at L1 and spinal arthrodesis from T10 to L3. The diagnoses listed spinal hardware failure, lumbago and L1 compression fracture. Anesthesia notes an American Society of Anesthesiologists (ASA) score of 2. He was seen by the Acute Pain Service.
The Acute Pain Services noted postoperative nausea and did not receive oral ketamine. Pain was controlled on a lidocaine drip and suboxone. It was noted to make Tylenol and Flexeril a standing order and continue suboxone on discharge, a 2-3 course of oral oxycodone when discharged. Neurosurgery noted a Jackson-Pratt (JP) drain with 215 cubic centimeters (ccs) output, a normal exam. Plan physical therapy (PT) evaluation, continue medications.
Neurosurgery noted JP drain 170 cc output, improved pain, x-rays done, exam normal. The next day the JP drain had 145 cc output. The JP drain had 41 cc output, likely discontinue JP drain and discharge.
At issue is the medical necessity of an inpatient stay.

Yes. The patient had a history of heroin use, initial presentation of a heart rate over 120 and his history of a fall due to relapse shortly after his spinal fusion that increased his kyphosis of a previous vertebral fracture at L1 with broken hardware. His suboxone needed to be decreased with monitoring prior to undergoing a repeat fusion. He would be considered high risk for adverse effects undergoing a planned repeat fusion. He met the guideline criteria as a lower level of care was not feasible or appropriate for his condition and treatment history.
He presented with a prior spinal fusion with broken hardware and a worsening kyphosis at his previous vertebral fracture. He had relapsed after surgery causing a fall. He was back on suboxone at 16 mg. He was admitted for detox due to the risk of severity of outcome for his future surgery. His dose of suboxone needed to be decreased and he was monitored for withdrawal. His presenting heart rate was 122 and felt to be due to withdrawal. He was monitored prior to surgery and after surgery required around the clock dosing for pain control as well as monitoring of his JP drain as well as every two hour neuro checks.
InterQual Inpatient & Surgical Care 25th Edition. Substance-Related Disorders Adult ORG: M-595
Treatment services available at proposed level of care are necessary to meet patient needs for Specific condition related to admission diagnosis is present and judged likely to deteriorate in absence of treatment at proposed level of care. (1)
"We have demonstrated that increasing amounts of preoperative opioid consumption may have a harmful effect on patient reported outcomes in those undergoing spinal surgery," said lead study author Clinton J. Devin, MD, assistant professor of orthopaedic surgery and neurosurgery at the Vanderbilt Spine Center.
"Our work highlights the importance of careful preoperative counseling with patients on high doses of preoperative opioids, pointing out the potential impact on long term outcome and working toward narcotic reduction prior to undergoing surgery," said Dr. Devin." (2)
Patients on chronic opioid therapy before spinal fusion are at increased risk of complications and adverse outcomes -- including repeated spinal surgery, according to the new research by Safdar N. Khan, MD, of The Ohio State University Wexner Medical Center, and colleagues. They write, "With increasing emphasis on cost containment and quality improvement, our findings are intended to caution providers about chronic opioid therapy as a risk factor for additional interventions and costs after lumbar fusion." (3)