Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck pain
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned

The patient is a male with a long-standing history of neck pain. He presented to the emergency room for neck and right arm numbness and tingling after being seen two times in another emergency department (ED) where an x-ray and CT (computed tomography) were done. He was seen by Pain Management and sent to ED for pain control/MRI (magnetic resonance imaging). He has failed Valium, prednisone, Advil. In the ED he received Flexeril, IV (intravenous) ketorolac, IV Dilaudid. Exam notes 4/5 weakness right upper extremity. A cervical MRI was completed for a C (cervical)5-6 broad based disc ridge encroaching the thecal sac, extruded subligamentous herniated disc with annular tear and C6-7 a posterior lateral extruded disc herniation compressing the right ventrolateral spinal cord, moderate right lateral recess stenosis, moderate right greater than left foraminal stenosis. He was placed in observational status and advised admission plan for possible surgery. Neurosurgery notes sharp pain to the right arm with difficulty writing but not dropping objects. 4/5 weakness in right intrinsic, positive Hoffmann's on right and right ankle clonus. States to admit for pain control and possible operating room tomorrow, NPO (nothing by mouth) after midnight, preoperative labs, medical clearance. He was cleared for surgery by Medicine.

He underwent right C6-7 posterior cervical foraminotomies and unable to get disc due to calcification. PACU (post-anesthesia care unit) notes no complications. Postoperative note reports normal exam. Plan to void, advance diet, ambulate, evaluate for discharge this afternoon. Lactated ringers at 125 ml (milliiters)/hr (hour) changed to Normal Saline with 20 meq (milliequivalents) /l (liter) of Potassium at 75 mls/hr. Patient reports neck pain and numbness to right upper extremity. Monitor overnight and may need cervical fusion via anterior approach. Pain control overnight. NPO after midnight. Dexamethasone stopped. Taking gabapentin, Celebrex, Tylenol x1, Dilaudid IV x1, Hydrocodone x3. Blood pressures (BP) 146/99, 158/101, 134/92. Neuro checks every four hours.

Given the patient's condition, he underwent a second surgery of a cervical disc arthroplasty and was monitored overnight for any complications given the second surgery. While a one level decompression and a cervical disc arthroplasty are commonly an outpatient/observation treatment, this patient had severe radicular and myelopathic signs with motor weakness, positive Hoffmann's and clonus that required around the clock pain medications, two surgeries and neurological monitoring. Once the patient was stable, he was discharged home. There are no guidelines available for this patient's condition specifically. MCG (Milliman care guidelines) does not mention the need for admission due to emergent surgeries, the need for around the clock medications or neurological checks. The patient did not meet clinical status under optimal recovery course. He still had pain and was not managed, his blood pressures were high due to pain, he was taking corticosteroids and IV fluids through day 2 and 3. The inpatient stay was medically necessary. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage is overturned. Medical Necessity is substantiated.