Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left (lumbar) Radiculopathy
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient was a male with history of hypertension, gastroesophageal reflux disease, stable aortic aneurysm, and prior spinal fusion of lumbar vertebrae (L)3-4 who underwent a posterior lumbar microdiscectomy L4-L5. The operation was performed without issue or complication. Post-operatively, his hemodynamics were stable and the patient was documented as awake and alert. The patient was placed in the hospital thereafter.

The patient had no complaints. His pain was well controlled without opiate therapy. Flatus was noted. His hemodynamics were stable and without hypoxia. The treatment plan included supportive care and therapy services. The patient participated in therapy and ambulated briefly with a rolling walker with weight bearing as tolerated with contact guard assistance. No other issues or complications documented later in the day.

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 clinical documentation provided, evidence based literature and standards of care, an acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care, such as the observation level of care with transition to outpatient services.
Clark et al. notes, lumbar radiculopathy, also referred to as sciatica, is a syndrome of radiating pain in a lumbar nerve root distribution that may also include motor weakness and sensory disturbances. Nerve root compression is typically caused by intervertebral disc herniation or degenerative changes and less commonly by infection, inflammation, neoplasm, vascular disease, or congenital abnormalities. Treatment may involve surgical management to address the underlying cause, nonsurgical management of symptoms, or both.[1]

The patient had a history of hypertension and lumbar radiculopathy who presented for an elective posterior lumbar microdiscectomy for L4-L5. The operation was performed without issue or complication. Post-operatively there was no documented acute issues or complications. On postoperative day (POD) 1, the patient had no complaints, his pain was controlled, bowel function was observed, hemodynamics were stable, and the treatment essentially consisted of therapy services. The patient participated in therapy and ambulated briefly with a rolling walker, weight bearing as tolerated, and with contact guard assistance. The patient remained in the hospital to allow for additional therapy services. No other acute issues or complications were documented. On POD 2, the patient was discharged.

Therefore, clinical indications for admission to inpatient care were not met. The patient did not have a severe infection, altered mental status, dangerous arrhythmia, hypotension, hypoxemia, presence of drug-related risk, impaired cardiovascular status, impaired respiratory status, acute kidney injury, clinically significant electrolyte abnormality, severe complication, or other postoperative event that warranted inpatient stay.[2]
 
The health plan's determination of medical necessity is upheld in whole.