Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient hospital stay for treatment of the enrollees acute low back pain without sciatica. Findings:  The physician reviewer found that the records demonstrate that this patient had a longstanding history of neck pain, back pain, complaints of generalized weakness, and depression. She was taking multiple analgesics and pharmacotherapeutic medications as an outpatient. She was hospitalized with an exacerbation of her low back pain without report of significant trauma. Examination showed that she was neurologically intact. Imaging showed a small avulsion fracture in the L2 inferior facet that was determined to be an old fracture. There was no clinical history indicating that she had sustained an acute back fracture. There was no clinical correlation on spine palpatory examination. There was no correlating imaging findings indicating that the fracture was acute. There was no spinal stenosis, foraminal stenosis, myelopathy, neurologic, or musculoskeletal pathology. Management was conservative, with recommendations for use of a corset, analgesics, muscle relaxants, and physical therapy. She remained neurologically intact. She was in no acute distress on examination. She was able to ambulate a short distance with physical therapy. There was no indication for continued acute hospitalization. There was no need for SNF services, skilled therapy or medical services on an inpatient basis for the patients condition. Further care could have been provided on a community or outpatient basis with durable equipment at home such as a walker and wheelchair, home based therapies, and custodial level support as needed. Further pain management could have been administered as an outpatient. Accordingly, the inpatient hospital stay was not medically necessary for treatment of this patients medical condition. In addition, the semi-electric hospital bed at issue was not medically necessary for this patient given the lack of documented impairments and clinical issues requiring frequent position changes only achievable with this type of equipment. Semi-electric and electric hospital beds are not needed for patients in the absence of significant impairments in organ systems such as the neurological, musculoskeletal or respiratory systems. Acute or chronic low back pain without a neurological deficit is not typical indication for use of this type of durable medical equipment. Given these findings, the semi-electric hospital bed at issue was not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services and device at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.