Appeal type: Medical necessity
Decision: Upheld

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

This male patient has a history of polysubstance abuse, bipolar disorder, hypertension, post-traumatic stress disorder (PTSD), anxiety, and back pain.  He presented with five days of back pain.  The pain was descried as sharp and radiating to the lower abdomen.  He has a history of discitis and lumbar abscess,  but didn't complete his post op course.  

The patient's vital signs (VS) revealed the following: temperature 97.5, heart rate 75, respiratory rate 18, blood pressure 126/74, and oxygen saturation 100%.  Exam was remarkable for low back pain on palpation.  Labs included the following: white blood cells (WBCs) 5.8, hemoglobin (Hgb) 9.9, alanine transaminase (Alt) 249, sodium (Na) 139, potassium (K) 4.3, and blood urea nitrogen (BUN)/creatinine (Cr) 17/.7.  Urine toxicology was positive for cocaine, opiates, phenyl cyclohexyl piperidine (PCP), cannabinoid, and methadone.  Computed tomography (CT) showed subacute to chronic discitis with marked irregularity of the L4-5 disc space with adjacent bony sclerosis as well as fat stranding in the anterior paraspinal region abutting the aorta and inferior vena cava (IVC).  

The patient was admitted for evaluation. On day two, vital signs were normal.  Neurosurgery consult was recommended, magnetic resonance image (MRI), neuro checks every one hour and Infectious Disease (ID) consultation.  The Infectious Disease (ID) consult recommended magnetic resonance image (MRI) and cultures.  On day three, vital signs were stable.  Transthoracic echocardiogram (TTE) was without evidence of vegetation.  He was to await the magnetic resonance image (MRI) and cultures.  Medical records were requested.  

On day four, the patient's vital signs were stable. The patient was awaiting cultures, magnetic resonance image (MRI), and records.  On day five, his vital signs were stable.  He was refusing labs. The patient was awaiting cultures, magnetic resonance image (MRI), and records.  On day six, the patient's vital signs were stable.  Magnetic resonance image (MRI) was without signs of infection.  The patient was recommended to complete antibiotics and re-image in two weeks.  On day seven, the patient's vital signs were stable.  He was awaiting Infectious Disease (ID) consult for antibiotics.  The patient signed out against medical advice (AMA).

No, the proposed treatment was not medically necessary.
This patient with a history of discitis and incomplete outpatient antibiotic therapy was admitted after presenting with back pain.  The patient was hemodynamically stable and afebrile.  He did not have leukocytosis.  Computed tomography (CT) was not remarkable for acute infection.  His exam was only remarkable for pain.  He did not have neurological deficits.  Plans for admission were for further evaluation.  Antibiotics were on hold.  Magnetic resonance image (MRI) was not performed until day four and was unremarkable for acute infection.  The patient was recommended to complete an antibiotic regimen.  The patient was clinically stable.  Other than pain, he did not have findings of acute infection.  He did not have uncontrolled pain.  He did not receive antibiotics or other intervention that required an acute inpatient level of care.  The requested inpatient admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.