Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain 
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is female patient with a history of peptic ulcer disease, morbid obesity, Roux-en-Y gastric bypass, diabetes, and L5-S1 disc herniation and S1 nerve root compression. She presented to the Emergency Department (ED) with complaints of lower back pain radiating down to the legs, chest, and arms and a urinary tract infection from a prior admission. She reported the pain was 9/10 in intensity. She was consulted by Neurology. On physical examination it was noted that she had right paraspinal vertebral tenderness, inability to fully bear weight on the right leg, no loss of sensation. She received oral Morphine for her pain. A chest x-ray was done which had normal findings. An electrocardiogram (EKG) was performed that revealed a normal sinus rhythm. She was evaluated by physical therapy (PT) who determined her pain was rated 7/10 and 10/10 with movement. PT's physical examination revealed that she required moderate assistance with upper extremity support for mobility and her gait, and she was unable to provide resistance on right lower extremity due to pain.  During her hospital course she was evaluated with continued treatment from physical therapy.  She was scheduled for an epidural steroid injection. She underwent a lumbar epidural steroid injection with sedation. She reported having relief from the treatment. She was discharged home with improvement in her condition. 

MCG Low Back Pain guidelines state, Admission is indicated for 1 or more of the following:  Cauda equina or conus medullaris syndrome as indicated by 1 or more of the following(11): 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 (eg, epidural abscess, vertebral osteomyelitis)(12)(13); Suspected cause that requires inpatient treatment (eg, aortic dissection); Severe pain requiring acute inpatient management; Immediate inpatient surgery; Other condition, treatment, or monitoring requiring inpatient admission. Severe pain requiring acute inpatient management; Severe pain requiring acute inpatient management as indicated by 1 or more of the following (1) (2)(3): Continuous or frequent (eg, every 2 to 4 hours) parenteral analgesics required[A] Necessity (ie, alternative approaches not effective) for analgesic regimen that can only be performed or initiated in inpatient setting. The goal length of stay is ambulatory or one day for Disk disease, spondylosis, or spinal stenosis as etiology of severe pain or functional deficit (without myelopathy); Anticipate therapy, medication, and possible surgical intervention.  Expect brief to moderate stay extension. 

Lumbar radiculopathy is one of the most common neurological complaints to be evaluated by a neurosurgeon practicing in a rural environment. While the pathology has not changed, newer, less invasive techniques are being developed to surgically treat these patients in the evolving field of spine surgery. Intimate knowledge of the signs, symptoms, red-flag warning signs, radiographic imaging, diagnostic tools, and conservative and surgical interventions is a necessity. The red-flag warning signs that would prompt an emergent evaluation include saddle anesthesia, incontinence to bowel or bladder, and sudden paresis in an extremity. (2)

The health care 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.