Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar stenosis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a male at the time who was admitted for lumbar stenosis.  His medical history includes diabetes, chronic renal insufficiency, cerebrovascular accident, and prostate cancer.  He presented to the Emergency Room via ambulance with a chief complaint of low back pain rated 9/10.  He had a Foley and prior arm numbness/weakness.  He had a stroke two months prior with difficulty walking over the past two weeks.  He complained of progressive worsening weakness of the bilateral lower extremities.  He reports he has been sitting in a recliner for two weeks with back pain and hasn't showered in three weeks.  He complains of fecal incontinence for two weeks.  The nursing notes describe, "his Foley is draining dark tea colored urine."  His catheter was to be removed.  He was soiled in feces, a stage 2 pressure ulcer to sacral area, blister noted to lower back.  It was noted that "Bugs" crawling on the patient's skin.  He was given Tylenol with effect.  His vital signs were within normal limits.  His white blood cell count was slightly high at 11 K, blood urea nitrogen (BUN) high at 66, creatinine high 2.2, glucose high 296 and anion gap high 15.  

Physician exam notes 4/5 strength in the right upper extremity and 3/5 in the bilateral lower extremities.  His lumbar MRI noted at L2-3 moderate spinal canal stenosis with effacement of the right lateral recess impinging on the descending right L3 nerve root and moderate right neural stenosis.
 
On one day a clinical indication for continued stay states he still had difficulty walking.  They were waiting for neurosurgery to make a surgical decision.  If not he would need sub-acute rehabilitation.  He also had a sacral decubitus and is morbidly obese.  The plan for x-ray of hip as his left leg is externally rotated, unlikely to be a fracture but would rule it out.  He was seen by Neurosurgery and states the patient has been non ambulatory since his stroke a few years ago.  He has no new symptoms.  The Neurologist offered no new plan for neurosurgical intervention.  On another day 19 orders for labs, remove Foley and do trial of Void (TOV).  The examination notes persistent weakness.  On a third day order for DuoNeb, obtained order for Ertapenem IV every 24 hours for seven days.  The Internal Medicine notes that the patient had not voided since the Foley was removed in the morning hours.  The examination notes confirm persistent weakness.  On a fourth day an order was obtained for "contact precaution" for Extended Spectrum Beta-Lactamase (ESBL) positive organisms.  He was then discharge to rehabilitation with peripheral IV and intravenous (IV) antibiotics.  The wound care notes did not provide degree of tissue damage, stated "un-stage able, moist eschar to the bilateral sacrum/coccyx" and new wound dressing orders were started.
 
The inpatient stay was medically necessary for the date range indicated.  He presented with severe back pain and the inability to walk.  He had significant motor weakness in the bilateral lower extremities 3/5.  He had a stroke two months prior and an emergency room visit two weeks prior for a dose of antibiotic for a urinary tract infection (UTI).  He would not have been safe at home as his wife was unable to care for him.  He could not have had the same care at a lower level until he was stable, with all the medical consultations and diagnostic testing completed, and subsequently transferred to a rehabilitation facility.  The inpatient admission meets criteria for acute inpatient management.

The health plan did not act reasonably and with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.