Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Back Pain 
Treatment: Emergency Treatment
The insurer is denied coverage for emergency treatment. 
The denial is upheld. 
This is a male patient who presented to the Emergency Department (ED) with lower back pain while working out 1 week prior to presentation. The patient stated that his low back pain was improving. The patient's mechanism of injury was heavy lifting. The patient's pain quality was described as shooting and sharp. The patient's blood pressure was 133/85, and the pulse was 81. The patient's physical examination revealed a positive straight leg raise at 60 degrees reproducing the complaint. The reevaluation indicated that the patient had symptoms consistent with lumbar radiculopathy secondary to disc herniation versus muscle spasm. There were no neurologic findings on examination. The patient was treated with ketorolac. The treatment plan included a follow-up with his primary medical doctor, nonsteroidal anti-inflammatory drugs, muscle relaxants, and steroids. The patient underwent a lumbar spine x-ray reviewed revealing no acute abnormality. The patient was discharged on the date of evaluation.

UpToDate notes, "The most common etiology of lumbosacral radiculopathy is ne rve root compression caused by a disc herniation or spondylosis, which is, narrowing of the intraspinal (central) canal, the lateral recess, or the neural foramen due to degenerative arthritis affecting the spine. The lateral recess is the most lateral space in the lumbar canal's triangular configuration, just proximal to the intervertebral foramen. It is bounded laterally by the pedicle, posteriorly by the superior articular facet and ligamentum flavum, and anteriorly by the vertebral body, endplate edge, or disk edge." This article also notes that "Acute back pain is the most common presenting complaint, often radiating around the anterior aspect of the thigh down into the knee and occasionally down the medial aspect of the lower leg as far as the arch of the foot. On examination, there may be weakness of hip flexion, knee extension, and hip adduction. Higher lesions may result in greater weakness of the hip flexors. Sensation may be reduced over the anterior thigh down to the medial aspect of the lower leg. A reduced knee reflex is common in the presence of moderate weakness."

In this case, the patient presented to the Emergency Department with left lower extremity pain. The patient denied fecal and/or urinary incontinence or hesitancy, or weakness of his legs. On physical exam, there were no neurologic abnormalities. The records did not support that the patient had acute symptoms of sufficient severity that warranted emergency level of care. The patient had the pain and had not sought, tried and failed outpatient medical care, such as urgent center or primary care provider. The patient could have presented to an urgent care clinic or his primary care provider instead of presenting to the ED for his chief complaint. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the emergency treatment provided is not substantiated. The insurer's denial should be upheld.