Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with a past medical history of migraines and polycystic ovaries. She presented to the ED (emergency department). The patient was reporting two months of progressively worsening low back pain. The pain was localized to the lower right back and radiated to the right leg. There was some tingling of the toes on the right foot. There had been no trauma preceding the onset of this pain. The pain had progressed to the point where it was difficult for the patient to ambulate. She had seen an orthopedist three days earlier who had recommended an outpatient MRI (magnetic resonance imaging). The patient was unable to get an MRI (magnetic resonance imaging) as an outpatient.

In the ED (emergency department), the patient had no documented neurological deficit. She was given one dose of morphine for pain control. An MRI (magnetic resonance imaging) showed disc protrusion at the L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) level causing impingement on the S1 (first sacral vertebra) nerve root. There was no evidence of cauda equina syndrome. Following her ED (emergency department) evaluation, the patient was admitted to the hospital.

The admission note for this patient indicates that she would be treated with IV (intravenous) Toradol for pain. She would be given several oral medications. IV (intravenous) morphine would be used for breakthrough pain. The patient would be seen in consultation by an orthopedist and a physical therapist.

The patient required one additional dose of morphine. The following day, her pain was improved. An orthopedist recommended a course of steroids by mouth. The patient was able to ambulate. Her pain was controlled with oral medication. The patient was discharged home.

No, the Inpatient admission was not medically necessary.
Following this patient's ED (emergency department) evaluation, she was clinically stable. An MRI (magnetic resonance imaging) had shown that her back pain was being caused by a disk protrusion in her lumbar spine. Clinically, there was no evidence of cauda equina syndrome. The MRI (magnetic resonance imaging) showed no evidence of cauda equina syndrome. The admission note for this patient indicates that her pain would be controlled primarily with oral medication and IV (intravenous) Toradol. Morphine would be used only for breakthrough pain. She would be seen in consultation by a physical therapist and an orthopedist. No other testing or consultations were anticipated for the patient.

At the time that this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a short stay in the hospital. For this reason, an inpatient level of care was not medically necessary. The patient could have safely been managed at an observation level of care. She had no severity of illness to justify an inpatient admission. There was no intensity of required services to justify an inpatient admission.

The patient was clinically stable following her ED (emergency department) evaluation. A limited plan of care was anticipated. The patient could have safely and effectively been managed at an observation level of care.