Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient is an adult male with degenerative disk disease who presented to the emergency room (ER) with back pain. The magnetic resonance imaging (MRI) confirmed left disk protrusion at lumbar three to four (L3-4) with compression of the left lumbar four (L4) nerve root. An urgent surgical discectomy was performed. 

The patient was noted to have severe left leg tingling, numbness, and weakness. He has been using a walker. On exam, his weakness was rated 4/5 in the left ankle. There was one week of symptoms noted.

The physician noted that the patient was recovering well from surgical discectomy and had normal motor strength.  After surgery the patient was given intravenous (IV) hydration and antibiotic prophylaxis. He recovered well and was discharged on the first postoperative day.

As noted, the patient presented with numbness and weakness that was progressive and severe and refractory to medical treatment. The MRI confirmed disk herniation at lumbar vertebrae (L)3-4 with compression of the L4 nerve root. Therefore, the patient was at risk for further loss of neurologic function. As such, the surgical intervention was medically necessary.

"Between each vertebral body of the spine are pads of fibrocartilage-based structures that provide support, flexibility, and minor load-sharing known as the intervertebral discs. These are primarily composed of two layers: (1) a soft, pulpy nucleus pulposus on the inside of the disc and (2) a surrounding firm structure known as the annulus fibrosus. A disruption of the normal architecture of these round discs can lead to a disc herniation or a protrusion of the inner nucleus pulposus, possibly applying pressure to the spinal cord, nerve root, or adjacent vertebral body which may further result in radiating pain and possible weakness. Slightly more than 90% of herniated discs occur at the lumbar (L)4-L5 or the L5-sacral (S)1 disc space, which will impinge on the L4, L5 or S1 nerve root. This compression produces radiculopathy into the posterior leg and dorsal foot" (Donnally III, C. J., et al. 2021).

"Back pain is one of the most common causes for patients to seek emergency care. It has a broad range of potential etiologies for both adult and pediatric populations. The etiologies differ depending on the patient population, but most commonly, it is mechanical or non-specific. Back pain causes significant rates of disability and can be a problem that persists from childhood into adulthood. It is essential to be able to evaluate patients of all ages and recognize the unique differences in the presentation in these different populations. Knowing the typical red flags of back pain in both children and adults can guide the provider to appropriate evaluation and treatment" (Casiano, V. E., et al. 2023).

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 inpatient hospital admission is substantiated.