Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient stay. 
The denial was upheld. 

The patient is a male with a past medical history of asthma, and hyperlipidemia, who was admitted for lower back pain and numbness. The review of systems was positive for lower back pain, numbness of the foot and difficulty ambulating. The patient was afebrile with a temperature of 36.6 and described as non-communicative and sleepy. His blood pressure was 164/117, pulse rate was 74, respiratory rate was 16, and oxygen saturation was 98% on room air. The physical examination was remarkable for left sided weakness of the leg.
His laboratory evaluation demonstrated a sodium of 140 potassium of 4.1, chloride of 105, carbon dioxide (CO2) of 23, blood urea nitrogen (BUN) of 20, creatinine of 0.78, white blood cell count (WBC) of 11.91, hemoglobin (Hgb) of 16.1, hematocrit (Hct) of 45.8, and platelets of 221.
The patient was admitted for lower back pain. The x-ray of the lumbar spine showed no fractures. The patient was evaluated by the neurologist who noted normal sensation, motor function and reflexes. A magnetic resonance imaging (MRI) scan of the spine revealed a lumbar (L)4-5 foraminal disc extrusion with caudal extension of disc material, posteriorly displaced left L5 nerve root. The patient was treated with Decadron, Dilaudid, a lidocaine patch and Neurontin for pain control. There was no saddle anesthesia or incontinence noted. The patient's leukocytosis was thought to be related to pain and workup did not reveal the presence of an infection. The patient was subsequently stable for discharge with outpatient orthopedic follow- up.
At issue is the medical necessity of the Inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient stay was not medically necessary for this patient.
Based on the documentation, the patient was admitted to acute inpatient level of care for management of lower back pain. The documentation does not support inpatient admission based on the lack of focal neurologic deficits, saddle anesthesia or urinary/bladder incontinence. The patient did not warrant surgical or procedural interventions for back pain. The x-ray of the lumbar spine showed no fractures. The leukocytosis was thought to be related to pain and there was no evidence of active infection.
Back pain affects most adults, is a leading cause of activity limitation and work disability worldwide and is among the most common reasons for seeking healthcare. The analgesic efficacy of opioids for acute pain is well established, and necessary to treat acute exacerbation of back pain. A systematic review by the American Pain Society and the American College of Physicians found no randomized control trials comparing opioids with placebo for acute low back pain. Instead, they reported "fair" evidence based on trials for other acute pain conditions. Additionally, clinical practice guidelines published in 2007 from the American Pain Society and American College of Physicians recommended against the use of corticosteroids for radicular or non-radicular low back pain. The use of systemic corticosteroids for low back pain remains relatively common. In this patient's case, an Inpatient stay for pain control with opioids and steroids was not medically necessary. The patient did not have neurologic deficits, saddle anesthesia or urinary incontinence that required an Inpatient stay.
Therefore, the Inpatient stay was not medically necessary.