Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Sciatica. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female with a past medical history remarkable for sciatica who was admitted for worsening back pain. A review of systems was negative for additional clinical symptoms. 
The patient was afebrile (temperature of 36.9C.). Her blood pressure was 129/68 millimeters of mercury (mmHg), with a pulse rate of 87 beats per minute (bpm), a respiratory rate of 18/minute, and an oxygen saturation of 96% on room air. A physical examination was remarkable for limited passive and active range of motion of the left leg. 5/5 strength of both lower extremities were noted. 
The patient was admitted for severe back pain and concerns for a sciatica flare. She was treated with intravenous (IV) Toradol, Morphine and a Ketamine drip. A magnetic resonance imaging (MRI) revealed a (lumbar-sacral) L5-S1 large central left paracentral disc extrusion causing compression of the thecal sac and left lateral recess stenosis. The patient was evaluated by neurosurgery, and it was recommended to treat this with Dexamethasone. Additionally, the patient was treated with Gabapentin and Diazepam for pain control. A review of the hospital course reveals that the patient was ambulatory and had no numbness or urinary symptoms. The patient was subsequently stable for discharge on oral Oxycodone. At issue is the medical necessity of the inpatient stay. 

The health plan's determination is upheld, in whole. 

No. The inpatient admission was not medically necessary at the inpatient level of care. The care could have been safely rendered at an alternate level of care. 
The patient was admitted for severe back pain and concerns for sciatica flare. The documentation does not support inpatient admission based on the lack of focal neurologic deficits, saddle anesthesia or urinary/bladder incontinence. The patient did not warrant urgent/emergent surgical or procedural interventions for back pain. The care could have safely been rendered at an alternate level of care for pain control and neurosurgery follow up. 
Back pain affects most adults, is a leading cause of activity limitation and work disability worldwide and is among the most common reasons for seeking healthcare. The analgesic efficacy of opioids for acute pain is well established, and necessary to treat acute exacerbation of back pain. A systematic review by the American Pain Society and the American College of Physicians found no randomized control trials comparing opioids with placebo for acute low back pain. Instead, they reported "fair" evidence based on trials for other acute pain conditions. Additionally, clinical practice guidelines published in 2007 from the American Pain Society and American College of Physicians recommended against the use of corticosteroids for radicular or non-radicular low back pain. The use of systemic corticosteroids for low back pain remains relatively common despite given rapid symptomatic relief of symptoms. 
In this case, pain control with opioids and steroids could have been administered at an alternate level of care with transition to oral pain medications.