Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Posterior lumbar (L) 4 - L 5 left micro-decompression
Treatment: full hospital admission
The insurer denied coverage for: full hospital admission
The denial is: Upheld.
This case involves an adult who had a full hospital admission. 

The patient presented for posterior lumbar (L) 4-L 5 left micro-decompression.  The patient is status-post previous L 4 - 5 decompression 8 months prior and was with relief of pain after surgery until approximately 5 weeks prior with recurrence of pain to lower back and radiating down to the left leg. The pain was constant and made worse with movement and no relieving factors. The patient has failed conservative treatment such as rest, pain meds, epidural injections, oral steroids, and Physical Therapy (PT). The patient denied any lower extremity numbness, weakness, or paresthesia. In addition, no fecal/bladder incontinence.  

The patient underwent L 4 - L 5 laminotomy, microdiscectomy, epidural fat graft with the use of operating microscope, local bone autograft, and interpretation of intraoperative fluoroscopy for chronic and debilitating radiating left radicular pain with magnetic resonance imaging (MRI) imaging demonstrating an L 4 - L 5 herniated nucleus pulposus compressing the L5 nerve root.  

The patient reported pain and was only taking Tylenol and Tramadol, + flatus, no bowel movement (BM) reported yet. The patient was voiding freely and denied dizziness, nausea/vomiting. 

The patient was seen and examined, reported that the pain was moderate. The patient's pain was controlled with Gabapentin, Toradol, and Tizanidine. Heart rate (HR) of 40-50 was noted and reported that the patient felt flushed, and also reported that the patient was hallucinating. Electrocardiogram (EKG) obtained and showed bradycardia (HR 54). The patient had post-operative asymptomatic bradycardia, EKG showed Nonspecific T wave abnormalities, anterior leads. Repeat EKG was stable, troponin was negative. Zanaflex and Ambien were discontinued.

The patient was seen and was alert and oriented to place, person, and time, the Jackson Pratt (JP) drain was in place, and the patient reported spasms. The patient noted with fair tolerance to physical therapy (PT) session and ambulating slightly. Hemoglobin (Hgb) noted at 11.7. The patient reported feeling better. With a little lightheaded/weakness. The patient's HR was 66. The patient reported some pain and dizziness. The incision was clean, dry, and intact. The patient tolerated PT session fairly. The drain was removed and the patient was discharged to home.  

Although the patient had bradycardia on post-operative day two, troponin was negative and repeat electrocardiogram (EKG) was stable. According to the Milliman Care Guidelines, the goal length of stay for the procedure was ambulatory. Inpatient stay may be needed for Older patients, Dural tear, cerebrospinal fluid leak, Extraspinal hemorrhage, Intraspinal hemorrhage, or Nerve root injury. The patient did not have a post-op complication such as Dural tear, cerebrospinal fluid leak, Extraspinal hemorrhage, Intraspinal hemorrhage, or Nerve root injury.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a full hospital admission is not substantiated.