Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shoulder pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a female.  There is a note indicating that the patient is a woman, who presented to the emergency room (ER) with back pain and shoulder pain radiating to the left arm for two weeks.  There was a previous history of right sciatica, hypothyroidism, and osteopenia.  The patient previously had been treated with medication and chiropractic management.  She was given Valium and Toradol and noted continued pain nine out of ten (9/10).  X-ray of the shoulder was done and intravenous (IV) morphine was given.  On reassessment, the patient still had uncontrolled pain, ten out of ten (10/10) and was admitted.  A magnetic resonance image (MRI) was performed showing cervical spondylosis with C4, C5, C7, and T1, neural foraminal stenosis.  The patient got a physical therapy (PT) evaluation and was consulted for discharge.  She was medically optimized and subsequently discharged.

A note indicated that the patient was prescribed cyclobenzaprine and ibuprofen; now the patient was with some relief.  The pain was rated 10/10.  Strength was 5/5.  The patient was reported to have uncontrolled pain 10/10 and was admitted.  Physical exam documented unremarkable review of systems except for left arm pain.  Physical exam documented she was alert and oriented times three with no focal deficits.  Pupils were equal, round, and reactive to light.  Extraocular eye movements were intact.

A note indicated the patient was ready for discharge.  

A note indicated the patient was able to ambulate on her feet with no assistance with verbal cues.  She had impaired swing bilateral with slow and steady gait with no loss of balance and required minimal verbal cues.

A note indicated no focal neurologic findings.  Reportedly the patient had osteopenia, hypothyroidism, and right-sided sciatica, and she was admitted with three weeks of left arm pain.  X-ray showed no acute fracture or dislocation.  She had mild stenosis on cervical (C)-spine.  She had slight weakness with some sensory loss in the left upper extremity, mainly in the fourth and fifth digits with suspicion of cervical radiculopathy and was awaiting ongoing treatment.

No, the inpatient admission was not medically necessary. 

The available medical records provided for review do not indicate findings that support medical necessity for inpatient admission.  The available medical records support the patient had uncontrolled pain despite measures taken in the ER, which would support a lower level of care than inpatient.  The available medical records do not indicate the patient was otherwise hemodynamically unstable, demonstrated any cardiac abnormalities or demonstrated any ongoing alteration of mental status or other focal neurologic disturbance in regard to motor, sensory, reflex, or coordination, or demonstrated a need for frequent parenteral intravenous (IV) pain medication to otherwise support medical necessity for inpatient admission.

Yes, the available medical records do support that the health plan did act reasonably, as the available medical records did not indicate findings of hemodynamic instability, focal neurologic disturbance, affecting the ambulating ability of the patient or other finding of laboratory, chemistry abnormality, that otherwise supported the necessity for ongoing hospitalization as an inpatient for the treatment of the patient.