Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute back pain with weakness of lower extremity.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a male patient with a medical history of Hodgkin's lymphoma treated with chemotherapy and now in remission with lumbar-4-5 stenosis who presented to the Emergency Department (ED) with complaints of back pain rated 10/10. The patient reported pain that was throbbing, constant and radiating to the entire body with associated leg weakness. The patient did not recall any inciting event and denied trauma.  He reported having chronic back pain for many years and stated that he had magnetic resonance imaging (MRI) in the past and was told he has mild stenosis. He reported pain increased over the prior 4 days and had become weaker on his left side. 

Physical examination noted the patient had obesity with limited strength testing of lower extremity due to pain with 4/5 strength. He was noted very uncomfortable and barely able to walk. X-ray of the lumbar spine showed no evidence of acute compression fracture or spondylolisthesis. The patient was seen by neurosurgery who recommended pain control and MRI. The patient received intravenous Morphine and Hydromorphone. The patient was admitted for further evaluation and management of acute back pain with weakness of lower extremity.  

An MRI of the cervical spine showed no acute changes or suspicious masses/ enhancement identified in the cervical, thoracic and lumbar spine but showed degenerative changes relatively mild in the cervical spine and most significant at T9-10 where there is a posterior disc protrusion indenting on the ventral spinal cord and in the lumbar spine they are most significant at L4-5 and L5-S1 showing a congenital spinal canal stenosis also noted in the mid to lower lumbar spine. The patient was seen and examined at the bedside and he stated that the pain was improving and denied any new numbness, tingling, no bowel or urinary incontinence.  A physical therapy evaluation was conducted with recommendation to follow with physical therapy outpatient. The patient was discharged home with instructions to follow up outpatient with his primary care doctor and physical therapy in 1 week and with neurosurgery appointment in 2 weeks.

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

The inpatient hospital admission is not considered medically necessary for this patient.

The patient was reported to have chronic back pain. There was no evidence of a medical condition to warrant the inpatient service (i.e. no bleeding, fever, infection). There was no documentation of failure to respond to oral analgesia. There was no evidence of a neurologic deficit nor necessity for immediate imaging. The patient did not require treatment for other underlying medical problems. The clinical record denoted improvement within hours. Physical therapy services, imaging and subspecialty consultations all could have been completed in the emergency department or a lower level of care. There were no extenuating circumstances to substantiate the acute inpatient admission. 

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.