Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male with a past medical history significant for hypertension, hyperlipidemia, and hemorrhoidectomy who presented to the emergency department with acute on chronic back pain. The patient stated that the back pain had been present for years. Reportedly, in the last 2 days that preceded his presentation, the back pain became significantly worse. He described a lower paraspinal pain that radiated down to the right leg. The pain was sharp, stabbing. The patient denied any recent back injury.
The patient had not taken any medications or received therapy for back pain in the past. This time he took Advil at home for pain with minimal relief of his symptoms.
When the patient was seen by the admitting physician, he was unable to sit up because of the pain. The pain was relieved by lying flat.
The patient reported fecal incontinence at baseline, which he attributed to hemorrhoidectomy, as well as intermittent urinary incontinence and increased urinary frequency over the course of 2 years with associated paresthesias in the groin area. The patient stated that he had a slightly enlarged prostate but was not taking any medications.
At the time of the admission, the patient denied nausea, vomiting, constipation, cough, fever, headache, vision changes, dysuria, chest pain, abdominal pain.
On the physical exam, the patient appeared to be not in acute distress. He was laying on his side to relieve pain. He was awake, alert, and oriented 3.
It was reported in the history and physical (H&P) note that the patient had no focal neurological deficits and had normal muscle strength in all extremities. The sensation was intact in the lower extremities. The rest of the physical exam was unremarkable except for very mild bradycardia and tenderness to palpation in the lumbar region.
Laboratory evaluation revealed that white blood cell count was 7.8, hemoglobin 16.8, hematocrit 50.5, platelets 279. Sodium was 137, potassium 5.2 on a hemolyzed specimen, chloride 101, bicarbonate 26, blood urea nitrogen (BUN) 13, creatinine 0.9, glucose 91. Troponin was negative. Electrocardiogram (EKG) demonstrated sinus bradycardia, otherwise normal. Magnetic resonance imaging (MRI) of the lumbar spine showed no compression of the conus medullaris or cauda equina.
There was small right paracentral disc herniation with extrusion at L1-L2 indenting the thecal sac, mild disc bulges at L2-L3, L3-L4, also small right lateral disc herniation at L4-L5.
Initially, in the emergency department, the patient received treatment with intravenous Morphine. He was admitted to the hospital and started on Ketorolac for pain management. Reportedly, the patient had a slightly elevated potassium level, but the specimen was hemolyzed.
While still in the emergency department the patient was seen by the neurosurgical team who determined that there was no role for acute surgical intervention. Pain management consultation was recommended.
During the short hospital stay, the patient received treatment with corticosteroids, Tylenol, and non-steroidal anti-inflammatory drugs (NSAIDs), with improvement in his pain level. The patient was deemed stable for discharge.

The health plan's determination is upheld, in whole.

The requested health service/treatment of inpatient hospital stay was not justified at the acute inpatient level of care.
This patient had chronic back pain that was related to chronic lumbar spine disc herniation. This admission occurred because of the acute exacerbation of chronic back pain.
During the short hospital stay the patient underwent MRI of the lumbar spine, which demonstrated no evidence of cauda equina or conus medullaris syndromes. A review of the medical records demonstrated that the patient had no severe or progressive neurologic deficits. There was no evidence that the patient's symptoms were related to spinal infection.
The patient was evaluated by the neurosurgical team and was recommended conservative treatment.
There was no evidence that the patient had any other medical conditions that could justify admission at the acute inpatient level of care.
This determination is also supported by Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 23rd Edition Criteria for Back Pain.
Based on the criteria, admission at the acute inpatient level of care is required for cases of cauda equina and conus medullaris syndromes associated with bowel or bladder dysfunction, saddle anesthesia, or neurologic abnormalities suggesting distal spinal cord impingement. The review of the medical records, including imaging studies and consultation reports from the neurosurgical service, did not reveal evidence that the patient had these conditions.
The review of the medical records did not reveal evidence that the patient had progressive or severe neurologic deficits, spine fracture, spinal infection, severe pain requiring inpatient management, need for inpatient surgery, and some other conditions that were not relevant to this clinical case.
In summary, this patient was admitted for a short period to get his pain under control and transition to oral medications to help control his pain going forward. These services did not require an inpatient level of care and could have been managed at a lower level of care status.