Appeal type: Medical necessity
Decision: Overturned

Diagnosis: low back pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned



This is an adult female who reported low back pain starting several months ago that has been controlled with medications. 2 weeks prior to admission, while she was at work, she was having low back pain, her colleague recommended stretches and cracked her back. She woke up the next morning with severe pain and was unable to ambulate. She was seen in the clinic and had a lumbar epidural with reported improvement. She had outpatient magnetic resonance imaging (MRI) done which revealed massive, extruded disc herniation with greater than 90% spinal compromise, causing severe nerve root impingement. The diagnosis was L5-S1 (Lumbar 5-Sarcal 1) herniated disc with radiculopathy. The patient has a medical history of morbid obesity with a body mass index (BMI) of 55.3.

The patient was referred to the emergency department (ED) for surgical consultation for spinal surgery scheduled for the following day. The patient was ambulatory without difficulty, declining a wheelchair. The patient had a history of bulging disc and reported lower back pain with associated numbness and tingling sensation down to the lower extremities for months. 

The patient was admitted to the orthopedic unit for intravenous (IV) steroids and pain medications. The examination was remarkable for tenderness to palpation in paraspinal muscles. Electrocardiogram (EKG) noted sinus tachycardia at 125 beats per minute, nonspecific ST (cardiac wave) abnormality. Significant labs included white blood cell (WBC) count 12.7 and absolute neutrophil count (ANC) 8.9. Urinalysis (UA) was remarkable for urinary tract infection (UTI). The chest X-ray unremarkable. 

The patient underwent L5-S1 (Lumbar 5-Sarcal 1) hemilaminectomy. 

Spine surgery is a traditionally invasive intervention with an extended recovery phase. Literature indicates coordination between care services before and after surgery and continual evaluation of postoperative course in spine surgery may provide reductions in complications, readmissions, length of stay, and opioid use, in combination with improvements in patient-reported outcomes and functional recovery.

Given the patient's clinical manifestations and diagnostic findings, acute inpatient stay is medically necessary for this patient. Magnetic resonance imaging (MRI) findings revealed massive disc herniation with greater than 90% spinal compromise, causing severe nerve root impingement and severe pain that requires emergency surgical intervention. Milliman Care Guidelines (MCG) indicate hospital evaluation and care needs for lumbar laminectomy may indicated for patients that require treatment with intravenous (IV) antibiotics, transfusion, and pain management. In addition, current literature indicates multidisciplinary approach to perioperative management after spine surgery decreases complications, readmissions and improves functional recovery. 

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 the full hospital admission is substantiated.