Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female. The patient had an inpatient hospital admission for the diagnosis of low back pain. The patient had a past medical history of hypertension and had a body mass index (BMI) of 30.8 with a history of asthma and diabetes type 2. The patient's glycated hemoglobin (A1c) was 7.7. The patient had a previous microdiskectomy at L5-S1 and then an anterior and lateral lumbar fusion and posterior fusion of L3-S1 last year. Postoperatively, the patient had begun to experience severe intractable pain that was not relieved by oxycodone, Neurontin, or tizanidine. The patient had radiating pain from her left thigh down her leg to her foot. The patient underwent magnetic resonance imaging (MRI) showing the fusion surgery. There was a residual disc fragment that contacted the left S1 nerve root. The patient was admitted for severe pain. The patient received medications including Neurontin, intravenous Tylenol, intravenous Toradol, and Dilaudid. The patient had a 
transforaminal epidural injection on day #2 and had mild reduction of pain. She was continuing on her medications. The patient was evaluated on day #3 and day #4 with continued pain symptoms and was continued on medications. The exam on day #5 showed continued pain into the left posterior thigh. The patient was evaluated in physical therapy on day #6 and ambulated 150 feet with a rolling walker. The patient was continued on Tylenol, Neurontin, Flexeril, and Dilaudid. The patient underwent a laminotomy of L5-S1 under general anesthesia on day #7. There were no complications. The patient was evaluated on day #8 and continued on her pain medications. The exam on day #9 showed continued pain symptoms and inability to ambulate 150 feet with a rolling walker or transfer independently. The patient was evaluated on day #10 and had acceptable pain symptoms and was discharged to home. The patient was cleared by physical therapy. This is a review for the inpatient level of care for the treatment provided to the patient.

The proposed treatment was not medically necessary.

The patient had a herniated disc causing radiculopathy. The need for an inpatient hospital admission was not established. The patient did not have any additional diagnoses that required treatment during the hospital stay and she was medically stable at the time of admission. The patient had a previous diagnosis of diabetes, but this was stable on the previous medication regimen and did not require workup and evaluation. The patient had radicular complaints due to a herniated disc. The patient had treatment with an epidural injection and then a lumbar diskectomy procedure. These procedures could have been provided on an outpatient basis. The need for the extended inpatient level of stay has not been established. The patient did not require any additional treatments or have any complications that required the inpatient level of care. The treatment was not medically necessary since standard treatment for patients with 
radiculopathy due to herniated disc would be an outpatient treatment unless there was additional diagnoses or complications. In this case, there were no additional diagnoses or complications that would require an inpatient level of care. Therefore, the proposed treatment was not medically necessary.