Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spondylolisthesis Grade 1

Treatment full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

The patient has a medical history of fibromyalgia, anxiety and hemorrhoids. She presented to the emergency room (ER) for 10/10 pain to the abdomen and pain around the rectum for two days and the inability to urinate. She noted she was only able to urinate by pushing down on her bladder and had 3 episodes of urinary incontinence in the past two weeks. In the ER, a foley placed for 300 cc clear yellow urine with relief of pressure. She was evaluated by the ER doctor who noted no motor or sensory deficits. Labs showed a low Calcium at 8.2 and estimated glomerular filtration rate (GFR) low at 75 ml/min (milliliter per minute). Her urinalysis was negative. Her CT [computed tomography] of the abdomen/pelvis showed bilateral L [lumbar] 5 spondylolysis with grade 1 spondylolisthesis and severe bilateral foraminal narrowing with compression of the exiting L5 nerve roots. Neurosurgery was consulted and ordered a lumbar MRI [magnetic resonance imaging]. Her lumbar MRI states a grade 1 spondylolisthesis at L5-S[sacral]1 with associated severe bilateral foraminal stenosis. Her recent outpatient brain MRI showed T[thoracic]2 hyperintensities in the midbrain/pons some on the left side. Her exam noted positive drift on the left, left upper and lower extremity grossly 4 to 4+/5 throughout. The assessment stated left sided weakness, visual disturbances, brain fog, T2 hyperintensities. The plan was for admission for further workup. Hold off on any surgical intervention and needs Neurology evaluation. Repeat MRI with contrast vs lumbar punction. She was seen by Internal Medicine and admitted with diagnoses of spondylolisthesis grade 1, weakness of left lower extremity, urinary retention, rectal bleeding, back pain. She was seen by Colosurgery who recommended colonoscopy in the morning. She was started on bowel prep overnight and had vomiting. She had no complaints overnight and slight headache. Her exam stable with grossly 4/5 weakness of the left side. The recommendation was for lumbar puncture after MRI with contrast and reconsult Neurosurgery if any concerns. She was seen by Neurology and was voiding normally. 

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

The inpatient stay was not medically necessary. Her care could have been provided at an observational level of care for her lumbar MRI to be completed. The patient had ongoing management by outpatient Neurology for left sided weakness. Her lumbar MRI was completed and was deemed to be not related to her present weakness. She did not have severe pain that required multiple doses of intravenous medications or frequent around the clock neurological checks. She did not require surgery. The inpatient stay does not meet MCG [Milliman care guidelines] Neurology as she had no new onset severe neurologic finding that required inpatient care. 

MCG Neurology 22nd Edition - Admission is indicated for 1 or more of the following: 
New-onset severe neurologic finding requiring inpatient care indicated by 1 or more of the following (28)(29)(30): 

-	Aphasia 
-	Weakness (eg, grade 3 or less) [B](31) 
-	Paralysis (eg, hemiplegia) (10)(32) 
-	Spasticity 
-	Dystonia 
-	Ataxia (21) 
-	Amnesia (33)(34) 
-	Involuntary movements (35) 
-	Vertigo 
-	Visual loss (36)(37) 
-	Other severe neurologic finding (eg, papilledema, mass effect on imaging, myoclonus) not treatable at alternative level of care (eg, observation care) 
or Guillain-Barre syndrome (2)

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