Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital.
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

This patient is a female admitted for diagnosis of spinal stenosis of the lumbar spine. The patient presented with chief complaint of trauma after falling down the stairs complaining of extreme lumbar pain.

Her vital signs demonstrated a blood pressure at 158/96, pulse was 98, respiratory rate was 18, temperature was 98.2F and oxygen (O2) saturation was 100%. Her physical exam showed moderate distress with abrasions to the left flank. There was no altered mental status or lumbar spine step offs. A chest x-ray showed no pulmonary consolidation or pneumothorax. A computed tomography (CT) scan of the chest, abdomen and pelvis with contrast showed no evidence of acute traumatic injury. The CT scan of the cervical (C) spine showed no acute fracture or subluxation. A CT scan of the head showed no acute intracranial pathology. The MRI (magnetic resonance imaging) scan of the cervical spine was not able to be tolerated due to pain. The MRI scan of the lumbar spine showed moderate bilateral subarticular stenosis impinging the lumbar (L)5 nerve roots.

The patient was treated with muscle relaxers and pain ultimately was able to be controlled. There was no orthopedic intervention recommended other than physical therapy and Physical Medicine and Rehabilitation (PM&R) consult was requested. The patient was recommended physical therapy with Flexeril and was discharged home on Flexeril, and tramadol as needed for pain. The patient was discharged with outpatient follow-up in the orthopedic spine clinic.

At issue is the medical necessity of the inpatient stay.

The plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.

According to Up-to-date, 2020: "Definitive Management And Disposition: The disposition of patients with spinal column injury depends primarily upon fracture stability and concomitant injuries. If a spinal column injury is deemed unstable, hospital admission and spine surgery consultation is mandatory. If consultation is not available onsite, immediate transfer must be arranged to a center that can provide these services. Patients with unstable fractures have commonly sustained multisystem trauma, and the extent of their other injuries determines whether they require admission to an intensive care unit or other monitored setting. (See "Initial management of trauma in adults" and "Overview of inpatient management of the adult trauma patient").

Nonoperative management of thoracic and lumbar spinal fractures involves the use of a spinal orthotic vest or brace. The goals of operative and nonoperative orthopedic intervention in spinal column injuries are to decompress neural structures, stabilize unstable segments, and restore alignment of the vertebrae [57]."

The patient in this case fell down the stairs, but did not have any fracture established based on MRI and CT imaging. There was no unstable fracture or additional injury causing hemodynamic instability such as a pneumothorax, pericardial effusion, or hypotension. The patient did not require surgery or have any bleeding. There was no fracture, subluxation, or dislocation of the cervical, thoracic, or lumbar spine. There was no focal neurological deficit.

Therefore, the requested health service/treatment of the Inpatient stay was not medically necessary.