Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Inpatient Stay. 
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who had a history of low back pain and left lateral calf and dorsal foot numbness with weakness. The symptoms began when she was working out. They improved with rest and physical therapy. She subsequently had a severe exacerbation of pain and numbness and weakness of her leg. She has tried medications, epidural steroid injections, physical therapy, and activity modifications. The physical examination demonstrated slightly decreased range of motion due to pain. Her Achilles reflexes were 1 out of 4 bilaterally, extensor hallucis longus (EHL) strength is 4 out of 5 on the left and the left straight leg raise is positive. 
The magnetic resonance imaging (MRI) of the lumbar spine demonstrates a broad-based central extrusion with an underlying bulge at lumbar vertebrae (L)5-sacral vertebrae (S)1 without central canal stenosis and mild right foraminal narrowing. Disc material contacts the descending left S1 nerve root without root displacement. The electromyography (EMG) demonstrates mild acute denervation of the left L5 nerve root innervated muscles consistent with L5 left radiculopathy. She was recommended to undergo an anterior lumbar discectomy and replacement at L5-S1. 
She underwent a lumbar disc replacement L5-S1. The estimated blood loss (EBL) was 10 cubic centimeters (cc). She tolerated procedure well with no documented complications. She was transferred to the recovery room in stable condition. Postoperatively her vital signs were stable and she was afebrile. She tolerated an oral intake, voided, and ambulated. Her pain was controlled with oral medication. She was subsequently deemed stable for discharge home. 

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. 

Based on the provided medical records, an acute inpatient hospital stay was not medically necessary per Milliman Care Guidelines, (Neurosurgery or Procedure General Recovery Guidelines (GRG):SG-NS), this claim does not meet criteria for an inpatient admission. The patient had a L5-S1 lumbar disc arthroplasty on the first day of admission and was discharged home 1 day later. The goal for length of stay, per guidelines, is ambulatory or 1 day depending on patient comorbidities and the need for postoperative monitoring. The scope of the care provided does not require an inpatient admission. Specifically, the floor to discharge and complete discharge planning criteria were met within 24 hours post procedure. Overall, the severity of disease, intensity of services provided, and documentation did not support and justify the necessity of inpatient admission. The patient had fulfilled all the floor to discharge, and complete discharge planning goals within the ambulatory timeframe. 
The patient's L5-S1 lumbar disc arthroplasty does not meet criteria for an inpatient level of care based on the above Milliman Care Guidelines. 

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