Is inpatient level of care medically necessary for a patient with cervical radiculopathy and moderate to severe left and mild right foraminal stenosis undergoing C7 to T1 anterior cervical discectomy and fusion for decompression, given ambulatory status per Milliman Care Guidelines (MCG) S-320?

Inpatient Level of Care for C7-T1 ACDF: Medical Necessity Assessment

For a patient with cervical radiculopathy and moderate to severe foraminal stenosis undergoing single-level C7-T1 ACDF, outpatient surgery is the medically appropriate level of care, with same-day discharge being safe and standard practice for appropriately selected patients. 1, 2, 3

Evidence Supporting Ambulatory Status

Safety Profile of Outpatient ACDF

• Single-level and two-level ACDF procedures can be safely performed on an outpatient basis with complication rates of only 1.4-3.9%, which are comparable to or lower than inpatient complication rates of 2-5% 1, 2, 4
• Meta-analysis of 2,448 outpatient ACDF patients demonstrated an overall complication rate of 1.8% with only 2% requiring readmission (mean follow-up 141.2 days) 2
• Population-level analysis of 3,135 ambulatory ACDFs showed 30-day ED visit rate of 5.4%, readmission rate of 1.6%, and reoperation rate of only 0.2% 3

Single-Level Surgery Supports Outpatient Status

• 63.8% of outpatient ACDFs in the literature involved single-level fusions, with virtually none extending beyond two levels 2
• Among single-level procedures specifically, 56% were successfully discharged same-day, compared to 43% for two-level procedures 1
• Your patient's single-level C7-T1 procedure falls well within established safety parameters for ambulatory surgery 1, 2

Critical Timing of Complications

• Critical postoperative complications involving respiratory compromise occur very infrequently and manifest in the immediate postoperative period, making extended inpatient observation unnecessary for appropriately monitored patients 1
• The single complication requiring readmission in one series involved neck swelling requiring only 23-hour observation 1

Patient Selection Criteria Met

Appropriate Surgical Indication

• The American College of Neurosurgery recommends ACDF for patients with cervical radiculopathy and moderate to severe foraminal stenosis, with 80-90% success rates for arm pain relief 5
• Your patient's moderate to severe left foraminal stenosis with clinical correlation meets surgical criteria 5

Absence of High-Risk Features

• Patients selected for outpatient ACDF should have limited comorbidities and undergo only 1-2 level procedures 4
• Population data shows ambulatory patients had mean Charlson comorbidity index of 0.2 compared to 0.4 for inpatients 3
• No mention of significant comorbidities that would necessitate inpatient monitoring in your case presentation 4, 3

Cost-Effectiveness Without Compromising Safety

• Overall charges for ambulatory ACDF are significantly lower ($33,362.51 vs $74,667.04) with comparable morbidity and readmission rates to inpatient procedures 3
• The primary impetus for outpatient surgery is cost savings, but this must not compromise patient safety—which the evidence demonstrates it does not 4

Recommended Certification

ZERO inpatient days should be certified for this procedure 1, 2, 4, 3

The procedure should be performed in an ambulatory surgery center with same-day discharge, provided:

• Patient has adequate home support for first 24 hours post-discharge 4
• No significant cardiopulmonary comorbidities requiring extended monitoring 4, 3
• Access to emergency care if complications arise 2, 3

Post-Discharge Monitoring

• Patients should be counseled that 5.4% may require ED evaluation within 30 days (mean 11.3 days post-op), most commonly for pain management, dysphagia, or neck swelling 3
• Only 1.6% require actual readmission, and 0.2% require reoperation 3

Common Pitfalls to Avoid

• Do not default to inpatient admission based solely on spinal surgery being performed—the evidence overwhelmingly supports ambulatory status for single-level ACDF 1, 2, 3
• Do not confuse medical necessity of the surgical procedure itself with necessity of inpatient level of care—these are separate determinations 5, 3
• Avoid certifying inpatient days when MCG S-320 already designates this as ambulatory, as doing so contradicts evidence-based guidelines and increases healthcare costs without improving outcomes 2, 3