Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back pain.
Inpatient Hospital Stay.
The insurer denied the inpatient stay.
The determination is upheld.

The patient presented to the emergency room (ER) with a chief complaint of back pain and vomiting. On presentation, she was afebrile with a blood pressure of 154/85, heart rate 77, respiratory rate 18, and with an oxygen saturation of 96% on room air. The exam otherwise noted tenderness to the low back, left to midline, with positive straight leg tests bilaterally. Labs resulted with a white blood cell count (WBC) of 14.48, hemoglobin (HGB) 14.5, platelets 342, sodium 140, potassium 3.9, blood urea nitrogen (BUN) 9, creatinine 0.64, liver function tests within normal limits, and urinalysis negative. Abdominal imaging showed no hydronephrosis or nephrolithiasis with small non-obstructing bilateral renal calculi. The patient was given intravenous (IV) Toradol with ongoing pain in the emergency room and hence was brought into the hospital with plans for pain control.
The patient remained hemodynamically stable without a fever, hypotension, tachycardia, tachypnea, or hypoxia. The patient noted that her pain was worse and was radiating down her right leg. Repeat lab results were unremarkable. Orthopedics saw the patient with the assessment that she likely had post laminectomy syndrome of the lumbar spine with sciatica with recommendation the patient would benefit from magnetic resonance imaging (MRI) of the lumbar spine and they noted that the patient was stable for transfer to a different hospital or for discharge and outpatient follow up if her insurance was not accepted by the hospital. An MRI noted that the patient was post laminectomy at lumbar (L) 4 with the soft tissue posterior to the laminectomy unremarkable and without evidence of fluid collection, abscess, or compression on the descending nerve roots with posterior disc bulge and mild bilateral facet arthropathy resulting in mild to moderate right and left foraminal narrowing and minimal central spinal canal stenosis. The patient was continued on IV Toradol, Flexeril, lidocaine patch, and as needed Zofran. She was seen by physical therapy and was noted to be able to walk to the bathroom with close supervision with home and outpatient physical therapy recommended. The patient continued to have ongoing pain. The assessment was that she would likely require surgery at some point that was not emergent. IV steroids were started. She was discharged. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient stay was not medically necessary. This patient presented with back pain with neurologic deficits or bowel/bladder symptoms. Within a reasonable period of observation, she was noted to be stable to discharged by the orthopedics team for outpatient follow up and eventual surgery that was not urgent. She had not failed multimodal pain medication therapy for her back pain at that point, with it noted that she could ambulate with physical therapy, with IV steroids started after which she was improved and was able to be discharged. This patient without concerning neurologic deficits or back pain requiring urgent intervention who was able to ambulate with physical therapy did not meet medical necessity for inpatient care as she did not fail multimodal pain therapy started within a reasonable period of observation or require intervention in the hospital.