Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dorsalgia and lumbosacral back pain 

Treatment: Inpatient hospital services

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

This patient is a male who presented to the Emergency Room (ER) with back pain on and off for three months. His pain was severe at this time rated 10/10 in intensity. He was unable to walk. He had numbness in his toes when bending forward. He denied any bowel or bladder symptoms or saddle anesthesia. He was not on blood thinners. His exam was normal. He was given Tylenol and a Lidocaine patch in the ER with good effect. The plan was for pain control, an ambulation test, MRI and preoperative treatment if necessary. The MRI showed moderate narrowing of the central canal and left lateral recess stenosis compressing the descending left L4 nerve root at L3-4, and severe narrowing of the central canal with compression of the descending left L5 nerve root due to left lateral recess stenosis at L4-5. He was admitted for the diagnoses of dorsalgia and lumbosacral back pain.

An attending note stated that the patient was referred for admission by Neurosurgery with concern regarding worsening back pain and possible impingement. There were no neurological symptoms and his ambulation was steady. He was pending an MRI.  Neurosurgery stated that the patient had a normal exam. The plan was for pain control and preoperative testing, and the surgery was planned. It was noted that the patient required more than 4 midnights as an inpatient. A disposition note signed stated that  the patient required admission for inpatient services and/or medically required inpatient diagnostic studies anticipated to span at least two midnights due to concern for serious outcome if he is not closely monitored as an inpatient. This was due to his severe back pain and difficulty with ambulation, as well as severe disc disease and nerve root compression and spinal canal stenosis.

In this case, there is no indication that he needed inpatient services prior to his surgery. There were no red flag findings. Medical records do not show that he was unable to ambulate, had routine IV pain medications, or had ongoing IV fluids. He did not have routine neurological checks. His laboratory studies showed no significant abnormalities.  His care could have been managed at an observation level until stable. The inpatient stay
does not meet InterQual Acute Adult Criteria (2016) - General for a Neurological Deficit with an acute exacerbation of known neurological condition, neurological assessment at least six times in 24 hours, CT or MRI scheduled or performed within 24 hours, medication adjustment or initiation, or pain, severe, intractable and unresponsive to equal to or greater than two doses of analgesics and pain assessment at least every four hours. 

Therefore, the inpatient stay prior to his surgery is not medically necessary. He underwent the lumbar fusion surgery and inpatient stay would be medically necessary for postoperative care and rehabilitation evaluation according to MCG Health Inpatient & Surgical Care, 22nd Edition, Lumbar Fusion ORG: S-820 (ISC).  The procedure, ICD-10 code 0SG007J is an inpatient procedure with a Goal Length of Stay of 3 days postoperative.

The insurer's denial of coverage for the inpatient hospital services is modified. Approve 3 days post-op surgery and deny 4 days pre-op surgery.