Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary.
 The health plan's determination of medical necessity is upheld.

The patient is a female with a past medical history significant for multiple sclerosis, diabetes mellitus, seizures, deep vein thrombosis (DVT) and pulmonary embolism (PE) on Warfarin, ulcerative colitis, and chronic back pain who presented to the emergency department with complaints of worsening back pain and bilateral leg pain that started on the day of admission. It was mentioned that the patient had multiple visits to the emergency department due to pain control issues associated with chronic back pain.
Upon presentation, the patient stated that her back pain was not adequately controlled with the oral pain medication Percocet. It was also mentioned that the patient had chronic bilateral lower extremity weakness, more pronounced in the right leg. She routinely utilized a cane for walking. In the emergency department, the patient was given an injection of Dilaudid with some improvement in her pain. Besides the injection of Dilaudid in the emergency department, the patient also received Solu-Medrol and Morphine. The review of systems was negative for diplopia, visual disturbances, vertigo, chest pain, shortness of breath, palpitations, bowel, or urinary habit changes.

The patient was admitted to the hospital with generalized pain/muscle spasms due to acute superimposed on chronic pain syndrome. The admitting physician wanted to rule out a multiple sclerosis flare. The patient was seen by a neurologist who suggested that generalized muscle pain and muscle spasms were not typical symptoms of multiple sclerosis. The neurologist suggested a magnetic resonance imaging (MRI) of the brain. Some additional laboratory studies were sent. The MRI of the brain was interpreted as an unremarkable study. There was no evidence of a multiple sclerosis flare. In the hospital, the patient was offered treatment with muscle relaxants, since it was suspected that her symptoms were related to muscle spasms. 
During the hospital stay, the patient remained in stable clinical condition. She was discharged from the hospital the next day after the day of admission.
At issue is the medical necessity of the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

No. The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
Based on the nationally accepted standards of care, admission at the acute inpatient level of care is usually indicated when patients present with back pain caused by 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, spine fracture with significant damage or threat of damage to a vertebral column or spinal cord, cases of suspected spinal infection, need for immediate inpatient surgery or when other causes such as aortic dissection are suspected, as the reason for the patient's back pain. The review of the nationally recognized criteria revealed that the patient had none of the circumstances listed above. Furthermore, the patient's hospital stay was very short. Considering the fact that the patient had multiple sclerosis, it was reasonable to admit her for observation to rule out multiple sclerosis flare and ensure adequate pain control.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at an alternate level of care rather than admission to an inpatient level of care. Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.