Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. The patient had an inpatient hospital admission for lumbar laminectomy. The patient had surgery with codes 63047 and 63048 for lumbar laminectomy for the diagnosis of spinal stenosis without neurogenic claudication.

The patient had preoperative low back pain complaints with pain with flexion and extension as well as lateral bending. The patient had pain into the right lower extremity. The patient had preoperative treatment with epidural injections, NSAIDs (nonsteroidal anti-inflammatory drugs) and physical therapy without improvement. The MRI (magnetic resonance imaging) showed a disc herniation at L3-4 (third lumbar spine vertebra-fourth lumbar spine vertebra) to the left as well as a bulging disc at L2-3 (second lumbar spine vertebra-third lumbar spine vertebra) and L3-4 (third lumbar spine vertebra-fourth lumbar spine vertebra) causing some foraminal narrowing. The patient had the surgery for an L3-L5 (third lumbar spine vertebra-fifth lumbar spine vertebra) laminectomy for spinal stenosis.

The patient was evaluated, and the dressing was clean and dry and intact. There was no calf tenderness, and ankle motor function and sensation were intact.

The patient was evaluated on day two and had stable vital signs and was afebrile. The patient had severe postoperative pain with difficulties ambulating and was able to void. The plan was to DC (discharge) home. The patient performed transfers and ambulation independently.

The patient was evaluated on day three and had continued pain symptoms, but this was improving. Drain output was decreasing. The patient was continued on IV (intravenous) antibiotics. The patient had difficulties ambulating.

The patient was evaluated on day four and the pain was improved. The patient had limited ambulation due to pain and the incision was clean and dry. The drains were continued.

The exam on day five showed the patient's pain was controlled with Valium.

The patient was discharged home. The patient had received IV (intravenous) cefazolin and metoclopramide for nausea. The patient also received oral Valium and oxycodone and cyclobenzaprine. The patient had received physical therapy during the hospital stay.

Physical therapy note indicated that the patient performed all functional mobility independently. The patient performed all transfers and ambulation independently, and therefore the patient was not a candidate for skilled PT (physical therapy) services. The patient was able to ambulate 200 feet. The patient was able to climb and descend stairs. The progress note indicated that the patient was comfortable at the bedside and in no apparent distress. The pain was well-controlled. The patient was planned for DC (discharge) home.

This is a review for the patient's inpatient admission.

The proposed treatment with the inpatient hospital stay is not medically necessary.
The patient had surgery for lumbar laminectomy. This is considered an outpatient procedure. There were no complications or additional diagnoses in this patient's case that would require inpatient level of care. The clinical notes from the following day after surgery showed that the patient had cleared physical therapy and was ambulatory independently. The patient had well-controlled pain, and vital signs were stable. The need for continued inpatient level of care has not been established. The patient had met discharge guidelines and could have been safely discharged at that time.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
According to the records, the patient had an outpatient procedure, and the day after surgery was independent in physical therapy with both ambulation, transfers, and stair climbing. The patient had stable vital signs, and the pain was controlled according to the medical record. The patient was taking oral analgesics. Given these clinical findings, the patient was safe for transfer to home and met discharge criteria. Thus, the health plan's denial was appropriate and in the best interest of the patient.