Diagnosis: Back pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, is not deemed medically necessary.

This is a male patient with a past medical history pertinent for hypertension, heart failure and COPD who presented to the ER for further evaluation/management of low back s/p mechanical trip and fall injury. Intake vitals were afebrile, hemodynamically stable with no evidence of profound tachycardia, hypotension or hypoxemia. Examination, labs and imaging were unremarkable for significant abnormalities, including no evidence of focal neurologic deficits or end organ damage. Medical records indicate the patient was admitted solely for observation/monitoring and treated with prn analgesics with significant improvement in symptoms. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.