Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbosacral Radiculopathy.

Treatment inpatient emergent admission.

The insurer denied coverage for inpatient emergent admission.

The denial is upheld.

This is the case of a male patient with a history of hypertension who presented for a scheduled lumbar level 4-5 (L (lumbar) 4-5) endoscopic hemilaminectomy, medial facetectomy and resection of the herniated disc at L4-5. The patient's pre/postoperative diagnosis listed herniated disc L4, L5, sacral (S) level 1 (S1) with lumbosacral radiculopathy and weakness of the extensor hallucis longus on the left. The American Society of Anesthesiologists (ASA) score was 2 and he had a body mass index (BMI) of 29. As per medical record, there were no documented complications during surgery. The patient was admitted after surgery and ordered intravenous (IV) Ancef, IV Decadron, IV Reglan, IV Zofran and physical therapy. Physical therapist saw the patient in the Post-Anesthesia Care Unit (PACU) and noted that he was unable to perform gait or transfer until medically stable. The patient was discharged from the PACU. The Neurosurgery stated that the patient's pain was well-controlled with overall improvement, foley was discontinued in the morning and the patient was voiding well. He ambulated with physical therapy and was ready to go home. The discharge exam was normal. The patient was discharged home.

As per Pendharkar et al., lumbar laminectomy with or without discectomy remains the most common spine operation performed in the United States and was one of the earliest procedures to be successfully transitioned to the outpatient setting (Table 1). Several groups have reported clinical series describing favorable outcomes. As per Pendharkar et al., "Helseth et al. reported on a series of 1073 consecutive patients undergoing lumbar procedures at a freestanding neurosurgical clinic with a successful discharge rate of 99.8% [percent] on the day of surgery. No patients died within 30 days, and the 90-day readmission rate was 1.5%. Nine patients (0.6%) suffered a postoperative hematoma, which was recognized and evacuated postoperatively, and these patients were subsequently discharged the same day... All data taken together, lumbar decompression has the strongest evidence for safety in the outpatient setting." As per Mikhail et al., lumbar discectomy performed through minimally invasive techniques has decreased recovery times with similar patient outcomes to open procedures. Performing lumbar microdiscectomy in the outpatient setting is safe, cheaper, and has better or equivalent outcomes to their inpatient counterparts. 

Based on the review of the medical record and literature, the patient could have been managed in observation.

The inpatient emergent admission was not medically necessary for a minimally invasive microdiscectomy. The patient's pain was controlled and was hemodynamically stable. He required a foley catheter for urinary retention postoperatively and was voiding the next day. The patient did not have any neurological deficits. He was able to ambulate and take oral pain medication and tolerate a diet the next day. The patient's inpatient stay does not meet Milliman Care Guidelines (MCG) exception criteria as he had no high levels of pain or vomiting that required multiple doses of IV medications. The patient's care could have been provided at an observational level of care.

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient emergent admission is upheld. Medical necessity is not substantiated.