Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain and fatigue. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

This case involves a male with type 1 diabetes, and Addison's disease, who presented to the hospital with a chief complaint of low back pain and generalized weakness for two days. The pain started immediately, as the patient lifted his wife after she suffered a seizure episode at home. The pain was sharp, 7 out of 10, aggravated by movement, and radiating into the legs. He denied any bowel or bladder incontinence. There were no other associated symptoms, such as fever or chest pain. There were no clear alleviating factors at home. The patient increased his chronic dose of hydrocortisone at home to alleviate the pain without success. 

His vital signs on admission included a blood pressure of 121/96, a pulse rate of 75, and a normal oxygenation status. On exam, the cardiopulmonary exam was unremarkable. Neurologically the patient was alert and oriented times (x) 3. 

The laboratory studies showed a white blood cell count of 5.3 and hemoglobin of 13.8. The electrolytes were stable. Magnesium was slightly low at 1.5, lactic acid was normal, and so were the coagulations. Cardiac troponin levels were negative x 3. The creatine kinase (CK) level was 102. A lumbar x-ray in the emergency department showed minimal degenerative changes of the lumbar spine. A chest x-ray was clear, and electrocardiogram (EKG) showed normal sinus rhythm. 

The medical team documented that the patient appeared fatigued and was seen by endocrinology in the emergency department (ED), to evaluate for concerns for adrenal crisis. The endocrine specialist recommended hydrocortisone, fludrocortisone, and intravenous (IV) fluids. The endocrinologist also recommended obtaining a respiratory virus panel to rule out a viral trigger for the possible adrenal crisis. 

He was transferred from a stepdown unit to the floor for a continuation of care. The patient had no other reported symptoms and could eat 50% of his meal. The vital signs remained stable. The IV fluids were discontinued at this point. The endocrine team recommended starting titration down of the hydrocortisone the following day. 

The patient was released home the next day, with a steroid taper, methocarbamol, and naproxen for the back pain. 

At issue is the medical necessity of the Inpatient Stay. 

The health plans determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient. 

Monitoring for the development of adrenal crisis does not require an Inpatient Stay. Inpatient hospitalization is not warranted in this case. The documentation fails to demonstrate any signs of a life-threatening illness acutely present in this patient to warrant a stepdown unit evaluation and treatment. Throughout the entire hospital stay, the patient's vital signs were stable, he was able to tolerate nutrition and hydration, and the back pain was responsive to nonsteroidal anti-inflammatories plus muscle relaxants. There is no documentation of mental status change, seizure activity, severe electrolyte derangements other than mild hypomagnesemia, labile blood pressures, or infectious causes precipitating an adrenal crisis. 

The patient was admitted to a stepdown unit due to concerns for an adrenal crisis but has no encephalopathy, had stable vital signs, seizure events, encephalopathy, and no major electrolyte derangements. The patient had symptoms of sciatica, which developed after he lifted his wife off the floor. This patient with known Addison's disease primarily presented to the hospital with back pain and some mild fatigue. Based on the provided documentation, there is no significant severity of the illness to warrant an inpatient hospitalization. 

Therefore, the requested health service/treatment of Inpatient Stay is not medically necessary.