Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain; Leg pain.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.   

This male patient has a history of low back and left leg pain.  The patient presented to the Emergency Department (ED) and reported that he was seen by another provider six months prior, where it had been recommended he undergo a lumbar decompression and fusion.  The patient chose conservative treatment.  In the ED, the patient reported had an acute exacerbation of pain for one week. The patient's history and physical note stated that the patient denied bowel or bladder incontinence, no saddle anesthesia, or gait imbalances.  The patient's physical exam noted paraspinal lumbar tenderness (left-side greater than right-side), mildly decreased sensation in the left L4-5, weakness in the left IP 4-/5, Q 4-/5, HS 4-/5, TA 4+/5, GS 4+/5.  The assessment and plan stated acute on chronic exacerbation of left lumbar radiculopathy, and to admit the patient for pain control and likely decompression.  The patient's lumbar magnetic resonance imaging (MRI) was pending; the patient was to be put on nothing-by-mouth (NPO) status at midnight and undergo preoperative studies and medical clearance. An operative report stated that the patient's diagnoses were neural foraminal stenosis and extraforaminal stenosis bilaterally at L4-5, foraminal stenosis and lateral recess stenosis on the left L5-S1, degenerative disc disease, spondylosis, back pain, and radiculopathy.  The patient underwent a left-sided transforaminal lumbar interbody fusion L5-S1, laminectomy left L5-S1, an interbody device to anterior interbody space L5-S1, extraforaminal decompression left L4-5, extraforaminal and foraminal decompression right L4-5, posterior spinal fusion L3-4 and posterior spinal fusion L4-5, and posterior pedicle screw fixation L3-S1.  The indication for surgery stated that the patient had prior conservative treatments of injections, narcotics, physiotherapy, and activity modification and was disabled from work. 

When conservative treatments fail to provide symptom relief, surgical intervention is considered.  The timing between surgery and when conservative measures can be designated as failed therapy typically ranges between four and eight weeks.  However, the question as to who would benefit from surgery and who should continue conservative therapy is debatable.  Overall, surgery has been shown to be of benefit to patients with more severe symptoms. Intimate knowledge of the signs, symptoms, red-flag warning signs, radiographic imaging, diagnostic tools, and conservative and surgical interventions is a necessity.  The red-flag warning signs that would prompt an emergent evaluation include saddle anesthesia, incontinence to bowel or bladder, and sudden paresis in an extremity.

Chronic mild neurologic deficits involving a single nerve root may not necessarily be considered a red flag because these deficits are common in patients with degenerative pathologies such as disc herniation and lateral stenosis.  However, a more aggressive approach is required when a patient has progressive neurologic deficits.

Based on the review of the medical record and literature, this patient's surgery was not emergent and did not need to be performed by an out-of-network provider. The patient had chronic back and left leg pain. The patient's physical exam showed minimal motor weakness throughout the left leg.  The patient denied bowel or bladder incontinence, saddle anesthesia, or gait imbalances. The patient had no red flag symptoms, and his motor weakness was not progressive or severe to qualify for emergency surgery.  The patient's surgery was planned on admission and performed two days later. There were no medical records to indicate a change in the patient's condition to where he needed immediate surgery to be performed by an out-of-network provider.

The surgery performed by an out-of-network doctor was not medically necessary.

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

The carrier's denial of coverage for the surgery performed by an out-of-network doctor should be upheld.  The medical necessity is not substantiated.