Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Inpatient Hospital
The insurer denied the inpatient stay. 
The denial is upheld.

The patient is a female who presented to the hospital secondary to worsening neck pain, radiating to the left arm and hand, described as aching and burning in nature. The pain was minimally improved with rest and analgesics medications. Previous treatment with epidural steroid injections provided only partial relief. The patient has a history of thyroidectomy, parathyroidectomy, open mitral valve repair, and myomectomy for hypertrophic obstructive cardiomyopathy. In addition, the patient had a single episode of atrial fibrillation, with no recurrent episodes. Functional status was acceptable, and the patient underwent preadmission testing in anticipation of cervical surgery.

The surgery took place lasting 1 hour and 9 minutes, status post anterior cervical decompression and fusion of C (cervical disc) 6 and C7 under general endotracheal anesthesia. Estimated blood loss was minimal, and the procedure was uncomplicated.

On postoperative day # (number) 1, the patient had no acute events overnight; the pain was controlled, the patient was voiding independently, and had positive flatus. There were no other reported symptoms. Vital signs were stable. Laboratory studies showed normal white blood cell count, normal renal function, and a calcium of 9.7. The dressing and incision were clean, dry, and intact, and the patient was placed in a cervical collar. The medical team assessed the patient on this day as well, and she reported some itching, flushing, and rash over the chest. The vital signs remained stable. The medical team suspected a mild allergy to chlorhexidine prep or tramadol. They provided the patient with Benadryl.

The next day the chest, face, and neck erythema resolved with Benadryl treatment. The patient ambulated with physical therapy 150 feet. The white blood cell count increased slightly to 12.8, but the rest of the labs appeared stable. In discussion with case management, the patient opted for home with home care on discharge, citing extensive family support. The patient was released in stable condition. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The provided documentation, delineating the patient's hospital course, was carefully reviewed. The patient presented for a planned two level anterior cervical decompression and fusion surgery. The patient has chronic medical problems, which are stable, and therefore was cleared for the surgery. The surgical procedure went as planned, without significant complications. Estimated blood loss was minimal. The patient had no significant complaints immediately postop. On postoperative day #1, the patient developed a chest, neck, and face rash, which resolved with the administration of antihistamine medications. There was no evidence of stridor, tongue swelling, or inability to handle secretions. Therefore, this was a mild allergic reaction either to topical medications or pain medications which were introduced postoperatively. The symptoms were mild and did not warrant an inpatient hospitalization. There was no evidence of wound dehiscence, bleeding, hematoma, airway compromise, swallowing inability, or signs of an infection. The development of mild rash, which did not affect the patient's cardiopulmonary status, does not warrant an inpatient stay. The patient could have been managed at a lower level of care status.