Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

The patient presented to the hospital via emergency medical services with complaints of low back pain that radiated down the left lower extremity. The patient denied trauma.  Triage vital signs noted blood pressure 161/79, heart rate of 65, respirations of 18, temperature of 98.0 degrees Fahrenheit (F), and oxygen saturation of 100 percent on room air. The emergency room provider stated that the patient had acute on chronic back pain for 10 years. There was a history of myocardial infarction and cervical disc herniation.  The patient was a current every-day smoker. There was history of L (lumbar) 4-L5 disc herniations. The patient had been unable to get up from a sitting position and called the ambulance. The patient rated their pain 10 out of 10. Physical exam findings noted lower lumbar, midline, and paraspinal left worse than right tenderness. There was decreased range of motion of the lumbar spine secondary to pain. Laboratory results noted white blood cell count of 12.94, red blood cell count of 5.16, hemoglobin of 16.0, and hematocrit of 46.8. Urinalysis showed 3-5 red blood cells, 0-2 white blood cells, occasional epithelial cells, occasional bacteria, and negative nitrite. A computed tomography (CT) of the lumbar spine showed multilevel discogenic degenerative disease and facet arthropathy that was most pronounced at L5-S (sacral) 1 with moderate to severe central canal narrowing and moderate bilateral neural foraminal narrowing. There was also mild right neural foraminal narrowing at L4-L5. The patient was given morphine, Decadron, and gabapentin for pain control. Neurosurgery was consulted and recommended magnetic resonance imaging of the lumbar spine. The patient had 5 out of 5 strength in the bilateral lower extremities with intact sensation. The patellar reflexes were 3+ bilaterally. The patient reported left radicular pain and numbness which were new for the past few days. The patient was admitted to observation. Follow-up evaluation revealed decreased sensation in the left S1 distribution with plantarflexion strength of 4+ out of 5. Magnetic resonance imaging of the lumbar spine revealed left L5-S1 disc herniation with lateral recess stenosis and an impression on left S1 nerve root. No acute neurosurgical interventions were recommended. The patient was to consult with pain management for epidural steroid injection. There was a planned epidural steroid injection. Due to herniated disc and sequestered fragment, there was a plan to admit to medicine. The patient underwent epidural steroid injection and the following day it was reported that the patient was not feeling much different. There was consideration for surgical intervention. The patient decided to go home with follow-up. The patient was cleared for discharge. 

Per the cited references, admission to the hospital is recommended for patients with low back pain when there is acute neurological deficit such as with bowel dysfunction, bladder dysfunction, saddle anesthesia, or other neurological abnormality suggesting spinal cord impingement, when there is severe pain requiring acute inpatient management, or when there is an etiology that requires inpatient treatment. Based on the documentation, the patient had acute on chronic low back pain with new symptoms into the left lower extremity. There was evidence of neurological deficits on exams which were reported to be new and worsening. This supports inpatient admission. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.