Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a male who presented to the emergency department for a past medical history of lumbar disc herniation with worsening back pain. His pain was severe rated 10/10 and notes indicate that he had mild improvement with Motrin but not responsive to Robaxin. He complained of numbness on his thighs, changes in sensation around the perineum, decreased erections and some lower extremity weakness. He needed help getting to the bathroom this morning due to lower extremity weakness. His exam noted that he was able to stand and walk with minimal assistance, no sensory or motor deficits. The plan was for a Neurology consult, analgesia should the patient request it, and dexamethasone. He would need spinal imaging but was not emergent at this time, probable inpatient management with neurosurgical follow up. He was admitted. He was given intravenous (IV) Decadron, oral Percocet and Neurontin. He was ordered IV morphine, but patient refused. In the emergency room (ER), labs were drawn, electrocardiogram (EKG) and chest x-ray completed. Neurology, Neurosurgery and Rehab consulted. Lovenox was ordered. He was seen by Medical who ordered Percocet every six hours as needed and follow neurosurgery recommendations. His exam was without focal deficits. A lumbar magnetic resonance imaging (MRI) done showed a small chronic central disc herniation at L (lumbar) 5-S (sacral) 1 with extensive degenerative changes and Schmorl's nodes without compression of the thecal sac or narrowing of the neural foramina. Neurosurgery notes he was scheduled for clinic the following day, but his boss insisted he go to the ER. He reports no acute change in his condition but has difficulty ambulating well sometimes with flare of pain. His exam states no gross tenderness, moving all extremities well, no gross focal deficits, strength 5/5. Recommended to follow up outpatient as scheduled, pain management prior to discharge. They then ordered a lumbar MRI and computed tomography (CT) scan. Neurology notes 10/10 pain, but describes mid back pain and a thoracic spine MRI was advised. He fell back in his chair from standing due to pain and took Motrin without relief. He was receiving care at a neurosurgery clinic outpatient. Exam states he points to the area between T (thoracic) 12-L2 and across the midline in the lower lumbar/sacral region. Saddle sensation intact and good anal sphincter tone. Reflexes 2/4 throughout. Gait cautious. Neurosurgery advised conservative treatment. Patient asking for epidural block. He may benefit from Pain Management consultation. PM&R (physical medicine and rehabilitation) seen and notes no weakness or sensory changes, not worse with facet closure maneuvers. Educated on body mechanics and recommend pain medication and therapy. Recommend referral to rehab clinic if interested. Mobility states independent, able to take a few feet bedside under supervision, moves with antalgic gait and unsteady at times. Recommend therapy and discharge home with home care. Lidoderm patch, consider NSAIDS (non-steroidal anti-inflammatory drugs) and muscle relaxant. A nurse note for in-house transfer no complaints of pain or discomfort, continent of bowel and bladder and ambulatory. A nursing admission note notes no pain and is ambulatory. Medicine states on hospital day 0, patient complains of chest pain, EKG ordered and negative, troponin negative. Medicine adds Flexeril, notes back pain responding well to pain medication. MRI completed and was unchanged from prior. 

The patient had an acute exacerbation of low back pain. He was given one dose of IV dexamethasone in the emergency department. He refused IV pain medication and did not take any oral Percocet. He was ambulatory without any neurological deficit. His studies did not show any compressive pathology. He was hemodynamically stable throughout his stay. His care could have been managed at an outpatient level of care. He was not a surgical candidate and was discharged home with follow up. The stay does not meet InterQual criteria for severe pain that is intractable and unresponsive to two or more doses of analgesic. The stay does not meet Neurology MCG as he had no new onset of severe neurological deficit.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.