Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal Cord Compression Fracture, Paraspinal Mass

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with medical history of breast cancer, hypertension and diabetes. She was transferred from a medical facility to the Emergency Department (ED) for evaluation of a new L4 spine mass seen on recent magnetic resonance imaging (MRI). The patient complained of pain to the lower back and weakness to lower extremities for a couple of months. She also complained of shortness of breath for a few days. She rated her pain 7 out of 10, in severity. A physical examination was performed that documented no neurological deficit or tenderness to palpation of the low back. The patient was given intravenous (IV) morphine with a favorable response. Neurosurgery and Radiation were consulted. She was admitted to the hospital with malignant neoplasm metastatic to bone. Her presenting vital signs were: temperature of 98.6, pulse 76, respiratory rate of 16, blood pressure of 207/74, and her oxygen saturation was 96% on room air. A chest x-ray was done and noted for no acute process. The patient had no fever, headache, chest pain, urinary incontinence but did complain of constipation. Laboratory work up was performed that revealed normal results. An electrocardiogram (EKG) was done that showed no changes from prior EKG. A lumbar magnetic resonance imaging (MRI) was performed that showed a mild compression fracture at L4 with no retropulsed fragments and diffuse enhancement of the vertebral body that extended through the pedicles and facets with faint epidural extension in the anterior epidural space; there was small enhancing paraspinal mass that extended slightly around inferior L3 and superior L5. The patient received (IV)  Decadron, IV morphine, and subcutaneous Lovenox. The patient signed out against medical advice and was stable for discharge on the same date of inpatient admission.

MCG Low Back Pain guidelines state, inpatient admission is indicated for 1 or more of the following: Cauda equina or conus medullaris syndrome (i.e. Bowel dysfunction; Bladder dysfunction; Saddle anesthesia); Neurologic abnormality suggesting distal spinal cord impingement; Progressive or severe neurologic deficit; Spine fracture with significant damage or threat of damage to vertebral column or spinal cord; Suspected spinal infection (e.g., epidural abscess, vertebral osteomyelitis); Suspected cause that requires inpatient treatment (e.g., aortic dissection); Severe pain requiring acute inpatient management, such as requiring continuous or frequent (e.g., every 2 to 4 hours) parenteral analgesics; Immediate inpatient surgery; Other condition, treatment, or monitoring requiring inpatient admission. In this case, this patient did not meet the MCG criteria for inpatient admission.

Inpatient admission was not medically necessary. The patient had two months of low back pain and bilateral lower extremity pain. The patient had a high blood pressure but she reported that this was her normal baseline. The patient was short of breath due to anxiety. The patient's labs were mostly normal, and her electrocardiogram (EKG) and chest x-ray was unremarkable. Neurosurgery deemed that this patient was not a surgical candidate for an L4 compression fracture and ordered a lumbar brace. The patient received intravenous (IV) Decadron and IV morphine with relief of pain. The patient was able to ambulate independently and take oral fluids and food. The patient was hemodynamically and neurologically stable. The patient's care could have been provided at an Observational level of care for consultations, imaging and pain control. 

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.