Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myelomalacia.

Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a male who presented to the Emergency Department after a fall at the post office, when he fell backwards and struck his head. His past medical history was significant for restless leg syndrome, asthma, and tobacco abuse. He also had cervical spine surgery a few years ago. He was lethargic and confused. His Glasgow Coma Scale (GCS) was 14. A level II trauma activation was initiated. Computed tomography of the head was unremarkable and computed tomography of the cervical spine showed no acute fracture. It was noted that he had a prior discectomy and fusion at cervical 3 - cervical 4 . Interbody graft demonstrated incomplete incorporation. He was admitted due to inability to clear the cervical spine due to cervical spine tenderness. Other than the confusion, his exam was normal. He was placed in a cervical collar. There were some episodes of sinus bradycardia and he complained of cervical pain.  A magnetic resonance image of the cervical cord showed myelomalacia at cervical 3-cervical 4 and at cervical 6-cervical 7 a disc bulge with flattening of the ventral cord.  

He complained of neck pain worse than baseline since the fall, but no arm pain or weakness. Neurosurgery was consulted to clear his cervical collar. Their exam noted left hand grip strength (which patient stated was a chronic finding). Otherwise, he had full left lower extremity strength, besides the new left-leg symptoms. Neurosurgery felt that the myelomalacia was likely an old finding related to the prior anterior cervical discectomy and fusion (ACDF)/ injury, in the absence of new weakness or numbness and tingling. Flexion and extension films were recommended. He underwent flexion and extension cervical films which showed normal alignment and no evidence of instability. A cervical collar was recommended until follow-up with primary neurosurgeon. He also refused to wear a cervical collar. He was noted to have a left lower extremity radiculopathy that was new since the fall. It started in the buttocks and traveled down into the bottom of the foot and heel. However, the patient opted to follow-up with his personal surgeon as an outpatient for this condition. He was discharged to home in stable condition with instructions for Neurosurgery follow-up.  

The inpatient admission was not considered medically necessary for this patient.

According to the Official Disability Guidelines (ODG) "Neck and Upper Back" chapter, hospitalization for neck and upper back conditions is "not recommended for neck pain in the absence of major trauma (i.e. acute spinal fracture, spinal cord injury, or nerve root injury), acute or progressive neurologic deficit, or the patient's inability to manage basic activities of daily living at home". The new-onset left leg radiculopathy did not warrant an inpatient stay, particularly in the absence of neurologic deficits. A retrospective observational study by Rizzardo et al (2016) of 1298 Emergency Department presentations of sciatica, lumbo-sciatica, and lumbago found that only 3.3% of patients required hospital admission, resulting in almost 48 times greater expense and mean length of stay of 15 days. The patient, himself, elected to have the new-onset sciatica worked-up as an outpatient. As such, the inpatient admission was not considered medically necessary.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld.  Medical Necessity is not substantiated.