Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Low back pain.
Treatment:  Inpatient hospital.

The insurer denied coverage for inpatient hospital.  The denial is overturned.

The patient is an adult male, who presented to the hospital with complaints of low back pain.  There was a history of lumbar (L)4- sacral (S)1 right-sided microdiscectomy.  The patient reported worsening right lower extremity pain.  The patient described unbearable pain with inability to ambulate, rest, or sit.  The patient complained of numbness and tingling that radiated from the lower back into the feet mainly on the right side.  Vital signs of the patient noted blood pressure 143/81, heart rate of 64, respirations of 17, temperature of 37.0 degrees C, and oxygen saturation of 100% (percent) on room air.  Physical exam noted right foot numbness in an L4-S1 distribution.  There was a plan for analgesia, neurosurgery consult, laboratory testing, and reassessment.  The patient had seen a treating provider outside of the facility 1 week prior with suggestion for microdiscectomy or two-level fusion.  The patient was interested in repeat microdiscectomy.  The patient complained of severe pain that radiated down the right buttock, posterior thigh, lateral calf, and into the right foot.  The patient had utilized ibuprofen without benefit.  The patient was not interested in pain medications that their pain management doctor prescribed due to side effects.  Medications given included gabapentin oral, intravenous Toradol, acetaminophen oral, Flexeril oral, and oxycodone oral.  The patient removed the lidocaine patches.  The patient received 1 epidural steroid injection that did not help pain.  The patient was admitted to the floor for observation with a plan for surgical intervention.  The patient received intravenous steroids without improvement in symptoms.  It was indicated that the patient was admitted emergently for increasing radicular symptoms.  The decision was made to undergo L4-S1 right-sided microdiscectomy.  The patient tolerated the procedure well.  There was an uncomplicated postoperative course.  

Per the cited references, admission to the hospital for low back pain is recommended when there is acute neurological deficit with bowel dysfunction, bladder dysfunction, saddle anesthesia, or other neurological abnormalities suggesting spinal cord impingement or when there is severe pain that requires acute inpatient management when pain is insufficiently responsive to nonpharmacological and nonopioid pharmacological analgesia, alternative routes for opioid treatment are not appropriate or not sufficient, and when intravenous opioid treatment is needed beyond observation care.  Based on the provided documentation, the inpatient hospital stay was medically necessary for the patient.  The patient had acute neurological deficit with neurological abnormalities suggesting spinal cord impingement which required surgical intervention.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.