Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe low back pain
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with no significant past medical history. She presented to the emergency room for severe low back pain for two weeks. The pain was noted to radiate to the left thigh.  She denied numbness, tingling, weakness, constipation, and incontinence. 

The patient's vitals at the emergency room were as follows: Blood pressure 116/63, temperature 98.1F, respiratory rate 18, heart rate 96, and oxygen saturation 97% on room air. On physical examination, there was tenderness to palpation in the left/right lower quadrant of the abdomen, left-sided Costovertebral angle; she had pain with passive flexion of the left hip.  There was no neurological deficit.

The patient's laboratory studies were as follows: WBC (white blood count) 5.1, hemoglobin 13.3, hematocrit 40.3, Platelets 420,000, potassium 4.1, creatinine 0.74, BUN (blood urea nitrogen) 10.5, sodium 140, ALT (alanine aminotransferase) 63, and urinalysis showed trace leukocyte esterase.

CT abdomen and pelvis, without contrast revealed that appendix measures seven mm (millimeters) in its proximal portion, concerning for appendicitis, as well as small umbilical hernia. 

The patient was admitted inpatient due to acute appendicitis.  History and physical by surgical service notes diagnosis of acute appendicitis; management plan includes IV hydration, pain medication and IV antibiotics.  Surgical attending consult noted working diagnosis of lumbar radiculopathy as well as unspecified, acute appendicitis. Repeat CT abdomen and pelvis with contrast  showed no interval change and no evidence of appendicitis.

Neurology consult noted diagnosis of muscle spasm of back and low back pain; there was no focal neurological deficit. Further hospital investigation includes unremarkable Lumbar spine MRI.

The patient was deemed medically stable and discharged home. 

The patient was presented to the hospital for complaints of low back pain. Initial hospital evaluation (CT abdomen and pelvis without contrast) was suggestive of acute appendicitis.  However, repeat CT abdomen and pelvis with contrast did not support acute appendicitis.  Working diagnosis per surgical service was lumbar radiculopathy.  However, MRI of the lumbar spine was unremarkable without evidence of high-grade foraminal stenosis. There was no evidence of focal neurological deficits or cauda equina syndrome. Hospital management/treatment was conservative, without any surgical intervention. For most patients with acute low back pain, bed rest, is not typically advised; however, patients are usually encouraged to perform activities as tolerated.  Furthermore, she was hemodynamically stable on admission; there was no evidence of sepsis, change in mental status, acute respiratory failure, active hemorrhage that required blood transfusion, cardiac arrhythmia, severe heart failure, acute renal failure, and severe electrolyte abnormalities.
 
The Inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.