Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain-paraspinal region

Treatment: inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial was upheld.

This patient is a female patient who was transferred from one hospital to another with a complaint of severe back pain after a fall.  The transfer centers pre-admit face sheet stated that the patient presented to the initial hospital and was subsequently transferred several days late.  The patient had a history of lumbar discectomy/ laminectomy in mid-2017 and 2 months status-post surgery had developed right lower extremity paresthesia and intermittent urinary incontinence.  There was report that the patient had bulging and ecchymosis of the lumbar spine above the previous surgical scar. Examination by the Neurosurgeon revealed the patient moved all four extremities with good strength except for the right lower extremity due to pain. The right foot had chronic foot drop, and there was decrease in sensation to the right lower extremity, with tenderness to palpation of the lower back region in the left paraspinal region.  The Neurosurgeon recommended admission as an inpatient for low back pain.  During the hospitalization the treatment course included intravenous Tylenol, and intravenous steroids and physical therapy.  The patient was discharged home with a Medrol Dosepak and was to follow-up with the Neurosurgeon.

The MCG indicate that referral management for low back pain and lumbar spine conditions is indicated for emergent evaluation or management of Neurosurgery for the evaluation or management of lumbar herniated disk and all of the following: failure of at least 6 weeks of conservative care, nerve root compression consistent with clinical findings evident on imaging, MRI, skin stigmata overlying spine associated with spinal defects, occupational medicine referral for evaluation or management of low back pain.
The MCG indicate that admission to inpatient care for back pain is indicated for cauda equina or conus medullaris syndrome as indicated by bowel dysfunction, bladder dysfunction, saddle anesthesia, neurologic abnormality suggesting distal spinal cord impingement, progressive or severe neurologic deficit, spinal fracture with significant damage, suspected spinal infection, severe pain requiring acute inpatient management immediate inpatient surgery.  
In the clinical records submitted for review, there was documentation that the patient was originally admitted to a hospital status post fall and refused treatment suggestions and was awaiting transfer to a hospital where her spinal surgeon could treat her.  The patient was subsequently transferred to the specified hospital and admitted.  However, the patient's condition did not meet the indications for admission to a hospital for referral with a Neurosurgeon or for low back pain that required inpatient care.  During the hospitalization, the patient was treated with IV Tylenol and Zofran, and there was no rationale provided for why the patient could not have been treated at a lower of care or have been given oral Tylenol and Zofran.  

Therefore, the inpatient hospital services were not medically necessary for this patient.  The health plan acted reasonably, with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.