Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical radiculopathy. 

Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This female patient has a history of severe chronic polyneuropathy that has been treated previously with prednisone and IVIG without improvement. It was felt she had progressive muscular atrophy and had not seen her Neurologist for awhile.  She presented to the emergency room for neck and left arm pain and numbness in the left lateral arm, near elbow and thumb and index finger for 10 days.  She had undergone an outside workup with a venous duplex ultrasound to rule out clots and x-rays, and was given naproxen that was not helpful.  Her pain was rated a 6/10 and she received oral Tramadol, diazepam and Percocet.  She was seen by Neurology who ordered Baclofen and increased her gabapentin.  Her exam noted left tricep reflex 4+, bilateral wrist extension 1/5, bilateral finger extension 0/5, bilateral thumb abduction 4-/5.  She had decreased tone in the bilateral wrists and slightly increased tone in the fingers.  She had decreased sensation to the LT/PP (lateral and posterior) left arm as well as fingertips of thumb and index fingers on the left. Her pain was reproduced with neck extension.  She was admitted to Neurology for pain management, magnetic resonance imaging (MRI) of the cervical spine and Physical Therapy/Occupational Therapy (PT/OT).  Her MRI noted a left paracentral disc protrusion at C6-7 likely impinging upon the exiting C7 nerve and resulted in mild cord deformity and mild canal stenosis.  There was moderate left neuroforaminal narrowing at C2-3.  There was a left paracentral disc protrusion with mild contouring of the left ventral cord for mild spinal canal stenosis at C5-6.  She was managed with Baclofen and gabapentin, and bilateral hand splints.  She was discharged home with an Occupational Therapy referral and Neuromuscular specialist. 

The patient had a 10 day onset of neck and left arm pain, some numbness and mild increased weakness.  She had a prior history of neuropathy that was ongoing and not the subject of her hospital stay.  She did not receive any intravenous pain management, did not take routine pain medication for intractable pain, and had no round the clock neurological assessments ordered. She did not have a spinal infection, a fracture, tumor, or severe cord/nerve root compression. She had motor weakness on exam, however this was chronic.  It was determined that she had cervical radiculopathy.  She was not deemed a surgical candidate and outpatient conservative treatment was recommended.  

The clinical consequence of radiculopathy is arm pain or paresthesia in the dermatomal distribution of the affected nerve and may or may not be associated with neck pain and motor weakness.  Patient history and clinical examination are important for diagnosis.  Further, imaging modalities, such as x-ray, computed tomography, magnetic resonance imaging, and electrophysiologic testing, are of importance.  Most patients will significantly improve from non-surgical active and passive therapies.  Indications for surgery are patients with clinically significant motor deficits, debilitating pain that is resistant to conservative modalities and/or time, or instability in the setting of disabling radiculopathy. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient did not meet criteria for inpatient stay and she did not present with any new, severe exam findings, have any infection, fracture, severe cord or nerve compression that needed emergent surgery. 

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.