Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of a lumbar microdisectomy L (lumbar)4-5, lumbar re-herniation L4-5, gastritis, ovarian cyst, sciatica and obesity. She presented to the emergency department by her surgeon for evaluation. She complains of low back pain with radiation to the right leg to calf with numbness in thigh/leg and mild weakness for two weeks, now with left leg pain. She had an MRI (magnetic resonance image) a month ago for herniated disc. Taking oral prednisone at home. Pain rated 6/10 at rest and 7/10 with activity in triage. Exam notes tenderness right back, diminished sensation right thigh and leg. No saddle anesthesia or bowel/bladder incontinence.  Physician states to increase pain medication and Ortho consult. MRI computed tomography (CT) with steroids. Her laboratory studies were within normal limits except glucose high at 158.  Medication given was oral Percocet x1, intramuscular (IM) Toradol, oral dexamethasone. Admitted for acute lumbar radiculopathy, possible recurrent lumbar disc herniation, pain control. Intermittent pneumatic compression, assess neurological status every eight hours, ambulate as tolerated, Decadron oral every 6 hours, protonix, Tylenol every eight hours, Robaxin every eight hours, oxycodone every six hours as needed, blood glucose testing four times a day with sliding scale insulin, Zofran intravenous (IV) as needed, regular diet, IV Toradol every six hours as needed, senna. Consult physical therapy/occupational therapy (PT/OT). Seen by Ortho for 4+/5 right hip flexion pain limited and decreased sensation to right lower extremity to knee. MRI and CT lumbar spine completed. Pain rating noted partial relief 4/10 at rest and 5/10 with activity. A nurse notes states that patient has remained hemodynamically stable, complains of pain, partially relieved with repositioning and pain medication. Pending transport. The receiving nurse writes no acute distress, no chest pain, shortness of breath, headache or blurry vision. Right leg pain and radiculopathy present. Plan for MRI. 

Nurse notes awake alert and oriented (AAO) x4 (person, place, time and event), no distress. Able to wiggle toes and reports sensation, has weak dorsi/plantar flexion in right leg. Complains of numbness and sharp pain along right leg. Pain controlled with current regimen. Out of bed standby and voiding, heat pack to lower back, tolerating diet. Seen by OT (occupational therapy) and notes she has no OT deficits at this time and was discharged. Pain rating 4-8/10. Lovenox ordered. Seen by Neurosurgery, unchanged exam. Took a shower. Wants to remain in hospital for pain control. 

Nurse notes no overnight events. Pain controlled with medications. Voiding and tolerating diet. She was discharged.

The patient could have been treated symptomatically while awaiting test results. There was no hemodynamic, pulmonary, neurological, or metabolic reason to treat the patient at an acute level of care.

The patient did not have any red flag symptoms and minimal neurological deficit. She was treated with oral pain medication and steroids. She was able to tolerate a normal diet, ambulate and void. PT (physical therapy) noted she had no deficits that needed services. Her MRI shows a recurrent herniated disc. She did not require frequent neuro checks. She wished to stay in the hospital for pain control until her surgeon returned. There were no frequent pain checks and no documentation of how frequently she required medication. There was no documentation of non-sufficient pain control and had no active adjustments to medications, dose or route ongoing that is required for MCG (Milliman Care Guidelines) Back Pain.  The inpatient stay does not meet criteria.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.