Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Shoulder Pain

Treatment: Inpatient admission

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

The patient has a past medical history of pain along the back of the right shoulder/trapezius region and decreased neck range of motion. The patient underwent cervical epidural steroid injections (ESI) which helped pain and range of motion. The patient continued to experience persistent numbness radiating down the entire arm into the pinky finger. Imaging showed evidence of right-sided foraminal narrowing at C (cervical) 3-4, C4-5, and C5-6. Diagnosis was cervical radiculopathy. 

The patient underwent a C4-C6 anterior cervical discectomy fusion (ACDF). Two attending surgeons were present, due to the complexity of the patient's condition and lack of available qualified residents. The patient's post operative assessment noted the patient was awake, verbal, and responsive with an anterior neck dressing that was clean, dry, and intact. One Hemovac was draining minimal bloody output, and c-collar was in place. The patient moved all extremities, strength 5/5, baseline numbness to right upper arm. Vital signs were stable, and the patient was afebrile. The nurse noted that when the patient was received from the Post-Anesthesia Care Unit (PACU), the patient was not stable for discharge at that time. Flow sheet note recorded that the patient ambulated to bathroom independently and that the patient was on intravenous (IV) antibiotic therapy as prophylaxis. The patient's vital signs were stable, afebrile, incision clean, dry, and intact. The patient took 2 Percocet tablets orally (PO), and subsequently the Hemovac drain was removed. The patient's cervical collar was in place. The patient was tolerating a PO diet, was out of bed with physical therapy, and was medically stable for discharge. 

Milliman Care Guidelines (MCG) S-310 ISC guidelines 27th Edition notes that patients discharged the day after surgery can be considered inpatients or outpatients, depending on regulation or contractual arrangements. Whether considered inpatients or outpatients, analysis of data for a commercially insured population shows 85% (percent) of patients undergoing a principal procedure of anterior cervical fusion were discharged the day of or the day after surgery. Operative Status Criteria: Ambulatory - 1-level or 2-level fusion at or below C3 in patients without myelopathy and without need for extended postoperative observation. Operative Status Criteria: Inpatient - Multilevel (3 or more) fusion, patients requiring extended postoperative observation (e.g., unstable comorbidities), or procedure on C1-C2 may require an inpatient admission. An analysis of 2000 ACDF patients in an ambulatory surgery center setting with a standardized perioperative protocol demonstrates that surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in a 4-hour PACU. 

The review of clinicals, guidelines, and literature found there was no reason this patient should have been placed in inpatient admission status. Observation status would have been sufficient. IV antibiotics are given in the operating room (OR) within the hour before incision. The floor nurse noted IV antibiotics prophylaxis which is not considered necessary after surgery if they received the pre-operative dosing. The patient ambulated to the restroom. The vital signs were stable. The dressing was clean, dry, and intact. The findings are upheld. This patient did not require an inpatient admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.