Diagnosis: Cervical Myelopathy

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient with history of cervical myelopathy, coronary artery disease (CAD), benign prostatic hyperplasia, bladder cancer, cystoscopy, appendectomy, diabetes mellitus, hypertension, and hyperlipidemia and underwent a scheduled, anterior cervical discectomy and fusion C3-C4. The patient's surgery was without complications and his preoperative neurological deficits returned to normal. The patient had episodes of high blood pressure that was controlled with intravenous (IV) medications and pain was controlled with a patient-controlled analgesia (PCA). The patient was seen by Cardiology and was noted to be in stable cardiovascular status. The patient was voiding, taking oral fluids and able to ambulate with walker. The patient's physical therapy (PT) suggested home discharge. The patient was discharged the following day in stable condition.

According to Yuk et al (2017), "Patients with anterior surgery performed experienced a length of stay that was 2.07 days shorter on average. Higher [estimated blood loss (EBL)], longer incisions, more intervertebral levels, and longer operating time were significantly associated with the posterior approach." As per Tetreault et al (2016), "A longer operative duration (moderate evidence)...s predictive of perioperative complications and a 2-stage surgery is related to an increased risk of major complications (high evidence). In terms of surgical techniques, higher rates of neck pain were found in patients undergoing laminoplasty compared with anterior spinal fusion (moderate evidence)."

In this case, the patient had an uncomplicated anterior cervical discectomy and fusion C3-C4 procedure and postoperative recovery. The patient had no neurological deficit and was able to void, ambulate and tolerate oral intake. The patient could have been safely monitored and treated in observational level of care. The patient did not have complications that required inpatient level of care. Thus, inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for inpatient admission is not substantiated. The insurer's denial should be upheld.