Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left hip pain, low back pain.
Treatment:  Emergency Department Visit.
 
The insurer denied the Emergency Department Visit.  The denial is upheld. 

No, the proposed treatment (ED visit) was not medically necessary. 

The patient is a male with no significant past medical history.  He presented to the Emergency Department (ED).  The chief complaint on the Emergency Department chart is "left hip pain".  The patient had been experiencing pain in his lower back that radiated to his left hip and down his left leg.  The pain had been present for three days.  There had been no trauma preceding the onset of this pain.  The pain was worse with walking.  Despite this, the patient was able to ambulate independently.  There was no abdominal pain or testicular pain.  There was no incontinence of urine or stool.  The patient had seen a chiropractor the day before but was still having pain.  No pain score is documented in the Emergency Department chart.  

Vital signs were normal in the Emergency Department.  The patient is described as being in no distress.  His physical examination describes mild tenderness to palpation over the left buttock.  The rest of the physical examination was normal.  No medications were dispensed in the Emergency Department.  No testing was performed.  The patient was diagnosed clinically as having sciatica.  He was discharged home with prescriptions for ibuprofen and prednisone.

In a letter written by the patient, he states that approximately ten days after his Emergency Department visit he underwent an outpatient magnetic resonance image (MRI) that showed a tear of the L3/L4 disc that was compressing the left L3/L4 nerve root.

This Health Plan covers Emergency Department services for the treatment of emergency conditions.  The health plan defines an emergency condition as a medical or behavioral condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in any of the following:  1) placing the health of the person afflicted with such condition in serious jeopardy; or 2) serious impairment to such person's bodily functions; or 3) serious dysfunction of any bodily organ or part of such person; or 4) serious disfigurement of such person.

The symptoms that brought this patient to the Emergency Department do not meet these criteria for being an emergency condition.  The patient's symptoms were neither sudden nor severe.  He had been having symptoms for three days already.  There is no mention of any visit to see a primary care physician during that time.  These symptoms cannot be considered severe.  The patient had isolated back pain radiating to his left leg in the absence of trauma.  Despite this, he was ambulating without assistance.  He had a benign physical examination.  There were no associated symptoms to suggest to a prudent person that a medical emergency was present that could place his health in serious jeopardy.  There was no reported weakness or tingling of the affected extremity.  There was no loss of any function.  No other body parts were affected.  From a review of the medical record, it is described that the patient was tolerating his back pain well.  He did not require any treatment for pain in the Emergency Department.

This patient did not need to be seen in a hospital Emergency Department to have his back pain evaluated.  The evaluation and management of acute back pain in adults falls into the scope of practice of a primary care provider.  The patient could have safely waited to be seen by a primary care physician.  There would be no expectation that a short delay in seeing a primary care physician would place the patient's health in jeopardy.  If an evaluation with a primary care physician was not possible, an urgent care center could have provided the same evaluation.

In conclusion, the patient's presenting symptoms do not meet the Health Plan criteria for being a medical emergency.  An evaluation in a hospital Emergency Department was not medically necessary.  The patient could have safely and effectively been evaluated at a lower level of care.  The Health Plan did act reasonably by denying coverage for an Emergency Department evaluation for this patient.