Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a past medical history of diabetes mellitus, prior gun shot wound to the left ischium with the bullet still in place, in addition to a prior fall, and presented to the emergency department with low back pain radiating down his left leg not associated with numbness, tingling, saddle anesthesia, incontinence, or erectile dysfunction.  The pain did not improve with Tylenol, Motrin, tizanidine, and prednisone, and it was noted that magnetic resonance imaging (MRI) to better characterize his pathology could not be obtained in the setting of the patient having a bullet wound, with difficulties obtaining authorization from insurance for an outpatient computed tomography (CT) myelogram also noted.

On presentation, he was afebrile with a heart rate of 105, blood pressure 154/92, and respiratory rate and oxygen normal.  The exam noted left sacroiliac joint tenderness and a positive straight leg raise on the left with normal strength and sensation in the bilateral lower extremities.  Labs resulted with a white blood cell count (WBC) of 12.59, Hemoglobin (HGB) 14.7, platelets 241, sodium 140, potassium 4.1, blood urea nitrogen (BUN) 22, creatinine 1.08, hemoglobinA1c 10.2%, and liver function tests normal.  A urinalysis showed glucosuria.  A pelvic x-ray and CT scan of the lumbar spine showed no acute fracture or compression deformity.  The patient was brought into the hospital with a concern for low back pain most consistent with lumbar radiculopathy without concerns for cord compression or neurologic deficits in addition to poorly controlled diabetes mellitus, and with plans for pain control, CT myelogram, and glucose control.

He remained hemodynamically stable.  He reported ongoing back pain but that it was improved somewhat with Tramadol.  No neurologic deficits were reported.  Physical therapy worked with the patient with the recommendation that he could follow up with outpatient physical therapy.  The plan for his back pain was ongoing attempts at pain control in addition to a CT myelogram with interventional radiology.  He otherwise was seen by endocrinology with recommendations made for Lantus, scheduled short-acting insulin with meals and insulin sliding scale.
 
The patient remained hemodynamically stable with no neurologic deficits.  He underwent a CT myelogram, which noted clumping of the nerve roots at lumbar (L) 3, which could be compatible with arachnoiditis, in addition to small central to left-sided disc protrusion at the L5-S1 level, which appeared to cause some mass effect on the proximal L5 nerve root.

The patient was discharged.

At issue is whether an inpatient stay was medically necessary.

An inpatient stay was not medically necessary.

This is a patient, who presented with ongoing significant back pain radiating down his leg despite attempts to control his pain with multi-modal pain control in the outpatient setting and with inability to get an MRI secondary to having retained bullet fragments in his ischium.  He was appropriate to bring into the hospital with concerns for need for ongoing pain control, physical therapy, and evaluation with CT myelogram to better define his pathology.  It is noted, however, that did not have neurologic deficits on presentation with no weakness or incontinence noted and without concerns for cord compression.  Given this, with the patient otherwise having no acute destabilized medical issues, it is unclear why he could not have been safely cared for at a lower level of care.  It is noted that his pain was able to be controlled with the patient fully ambulatory within a reasonable period of observation.  Inpatient level of care was not medically necessary.

A lower level of care was appropriate for this patient presenting with ongoing significant back pain radiating to his leg despite multi-modal medication therapy as an outpatient, who did not have neurologic deficits, concern for cord compression, or other destabilized medical issues.