Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal / Back Pain. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient has a past medical history significant for sciatica, herniated disks, brain arteriovenous malformations (AVMs), arthritis, seizure disorder, and anxiety who presented to the hospital with a 2-day history of worsening lower back pain. The patient had been working out in the gym, at which time he felt an "electric shock" down his left lower extremity. The patient took Gabapentin without relief of his symptoms. The patient stated that he had difficulties with ambulation due to pain. The review of systems was positive for arthralgias and gait problems. The rest of the review was negative. At the time of admission, the patient was diagnosed with back pain. The admitting physician stated that the patient most likely pulled a hamstring. It was indicated that on the exam the patient had a negative straight leg raise test. Pain control with Toradol, Lidocaine patch, Flexeril, and Percocet was initiated. A magnetic resonance imaging (MRI) study of the lumbar spine demonstrated left lateral recess disc extrusion at lumbar (L)5-sacral (S)1, which compressed the descending left S1 nerve root. Additionally, there was moderate degenerative bilateral neural foraminal narrowing at this level. 
In the hospital, a pain management specialist saw the patient. The pain management specialist recommended avoiding the parenteral administration of opioids. At the same time, treatment with intravenous Toradol was advised. The patient also received short treatment with oral opioids, muscle relaxants, and Gabapentin. In addition, the patient tested positive for COVID-19, however, he was asymptomatic including normal oxygen saturation on room air. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. 

Based on the nationally accepted standards of care, admission at the acute inpatient level of care for patients presenting with back pain is usually indicated when neurologic deficits are present. Usually, these deficits manifest in bowel dysfunction, bladder dysfunction, or saddle anesthesia. The review of the medical records clearly demonstrated that the patient had none of that. 

Furthermore, there was no evidence that the back pain was associated with serious conditions such as aortic dissection, epidural abscess, or spinal instability. Even though the patient had severe back pain initially, this was treated effectively within a short period of time. The hospitalization lasted two days and during this period of time, reasonable pain control was achieved. This patient did not require any surgical intervention, and overall remained in stable clinical condition. Therefore, admission for a lower level of care was most reasonable, considering the clinical circumstances. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at the observation level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.