Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Worsening back pain, s/p fall
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the proposed treatment is not "medically necessary.

The patient is a female who presented to the emergency room with complaints of back pain after a fall, six days prior.  She rated her back pain as ten out of ten (10/10), which radiated to the left leg.  Per medical records, the patient was unable to get out of bed today and called EMS.  She denied loss of consciousness, lightheadedness, chest pain and shortness of breath, incontinence, and focal weakness in arms or legs.

Past medical history included coronary artery disease (CAD) status post stent, type I diabetes mellitus with neuropathy, herniated lumbar intervertebral disc, cervical radiculopathy, hypothyroidism, systemic lupus erythematosus, hyperlipidemia, and peptic ulcer disease.

Emergency room vitals: blood pressure 112/72, pulse 60 beats per minute (bpm), respiratory 18, temperature 97.5F, and oxygen saturation 100% on room air.  

Physical examination (emergency room) was notable for tenderness to palpation over the left abdomen, limited range of motion of the right shoulder secondary to pain, limited range of motion left leg secondary to pain, and tenderness to palpation of left lateral lower back.  Neurological examination was notable for limited strength in the left shoulder and left leg. 

History and physical at the time of admission, noted that the patient moves all extremities without no leg weakness.

Laboratory studies: white cell count 8.71, hemoglobin 12.5, hematocrit 38.0, platelet 347, sodium 135, potassium 4.0, glucose 128, blood urea nitrogen (BUN) 12, creatinine 0.77 and hemoglobin A1C 7.9.

Electrocardiogram showed sinus bradycardia with heart rate of 48 beats per minutes.

Computed tomography (CT) of the abdomen and pelvis revealed no acute pathology; colonic diverticulosis without diverticulitis.

Chest radiograph showed small linear opacity in the right lower lung field which may represent atelectasis versus scar. 

Right shoulder x-ray was unremarkable.

Assessment was acute left-sided low back pain without sciatica.  Treatment received in the emergency room included Tylenol, lidocaine patch, and intravenous morphine.

The patient was admitted to inpatient status, for low back pain.  Follow-up hospital consult by cardiology recommended discontinuation of Plavix. 

The patient was deemed clinically stable and discharged home.

The patient presented to the hospital due to acute left-sided low back pain without sciatica.  However, radiological study did not show acute fracture, dislocation, and no evidence of high-grade foraminal stenosis in the lumbar spine. Physical examination in the hospital did not support focal neurological deficits or cauda equina syndrome. Hospital management/treatment was conservative, without any surgical intervention recommended. For most patients with acute low back pain, bed rest, is not typically advised; however, patients are usually encouraged to perform activities as tolerated. Furthermore, the patient was hemodynamically stable on admission; there was no evidence of sepsis, change in mental status, acute respiratory failure, active hemorrhage that required blood transfusion, cardiac arrhythmia, severe heart failure, acute renal failure, and severe electrolyte abnormalities. The proposed treatment was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.