Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Orthopedic/Musculoskeletal. 
Treatment:  Inpatient Hospital. 

The insurer denied the inpatient stay.  The denial was upheld in whole.

The patient is a female with a past medical history significant for back pain related to previous episodes of disc herniation, who presented to the emergency department with complaints of left-sided back pain that radiated down the leg.  Reportedly, the back pain started a few days before the presentation and became progressively worse.  Despite having pain, the patient reported no numbness or paresthesias; there was no urinary or fecal retention or incontinence.  The patient denied fever, neck stiffness, or a recent history of trauma.

On the physical exam, the patient appeared non-toxic and in no apparent distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops.  Lungs were clear to auscultation without wheezing, rales, or rhonchi.  The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound.  On the neuro exam the patient was awake, alert, was moving all extremities.  The muscle strength in the left lower extremity was limited because of pain.  The sensation was intact throughout.

During the hospital stay the patient was seen by a palliative care/pain management specialist, who stated that the patient was initially admitted to clinical decision unit (CDU) for pain management.  However, her pain was still inadequately controlled in order to discharge her home.  This prompted admission to the medical floor, and her admission status was upgraded to full inpatient admission.

It is important to emphasize that the patient's pain management regimen included the administration of Ketamine infusion while in the emergency department.  Subsequently, the patient was switched to intravenous Morphine while in the CDU.

While on the medical floor, the patient was transitioned to a combination of several oral medications aimed to treat back pain.  The patient was subsequently discharged home.

The health plan's determination is upheld in whole.

Based on the accepted standards of care, admission at the acute inpatient level of care in patients with back pain is usually required in cases of cauda equina and conus medullaris syndromes associated with bowel dysfunction, bladder dysfunction, saddle anesthesia, neurologic abnormalities suggestive of distal spinal cord impingement, also in cases of progressive or severe neurologic deficits, cases of spine fracture with significant damage or threat of damage to a vertebral column or spinal cord, cases of suspected spinal infection, or severe pain requiring acute inpatient management.  In this particular case, the patient indeed had severe pain; however, she required administration of parenteral pain medications for only a relatively short period of time.  During this short admission, the patient was switched to oral medications fairly quickly.  
It was indicated that the patient had Ketamine infusion while in the emergency department and some intravenous Morphine while in the CDU.

When the patient was admitted to the medical floor and her admission status was converted into an inpatient level of care, she was switched to a combination of different medications aimed to treat acute back pain.  The review of the medical records also revealed that the patient did not require immediate inpatient surgery.  Taking into consideration all the circumstances, the patient could have been managed at a lower level of care status.