Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Radicular pain of the left shoulder

Treatment: Inpatient admission

The insurer denied coverage for an inpatient

The denial is overturned.

The patient who presented to the emergency department with a sudden onset of severe left shoulder and arm pain. It was associated with weakness, tingling and limited range of motion. She took tramadol and had a trigger point injection in the emergency room yesterday without relief. Her pain was rated 10/10 (on a pain scale of 1-10).  Medical and surgical history includes hyperlipidemia and left shoulder surgery. Her exam noted limited range of motion, tenderness and some weakness in the triceps/biceps/deltoid but difficult to assess due to pain. She received Percocet, gabapentin and Lidocaine patch with some relief, pain rated 7/10. The patient wanted to stay for a cervical and thoracic MRI (magnetic resonance imaging). At this time, no urgent further follow up is required. Her diagnosis was radicular pain of shoulder. She was placed in observation for pain control and imaging.

The inpatient stay was medically necessary for pain control, multiple consultations, changes in pain medication for ongoing pain not relieved by oral routes alone. She received IV (intravenous) Decadron and oral Decadron as well as ongoing IV morphine as needed for severe pain. She had a prior emergency department visit with outpatient medications that were not effective. The inpatient stay meets MCG (Milliman Care Guidelines) musculoskeletal pain criteria.

Pain is one of the main complaints of patients referred to the hospital and comprises almost 80% (percent) of the causes for referral to the emergency department (ED) (1, 2). Pain management in the emergency department is one of the quality-of-care indicators and can be used as a marker for assessing the care in the ED (3-7). Factors such as race, age, sex, ability to express pain, underlying illness, physician awareness, and fear of complications can prevent proper pain control in patients. Pain control should not be delayed while waiting for test results and paraclinical actions. The primary basis for pain relief is the administration of systemic analgesic agents such as narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs) (8-10). The type of treatment regime should be chosen and administered in a way that, in addition to being able to improve several types of pain in the patient, have few side effects and do not interfere with other drugs (11). Studies have shown that patients whose primary pain is well managed and treated in the ED have a higher overall satisfaction with hospital services (12-14). However, there is an almost universal agreement about the inadequate treatment of pain in the ED (2, 15). As a result, recognizing different methods of analgesia and pain management for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services. (2)

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.