Diagnosis: Back pain
Issue under review: Inpatient admission

Determination: The inpatient admission was not medically necessary.

The patient is an adult female with history of HIV (human immunodeficiency virus), asthma, hepatitis C, coronary artery disease status post PCI (percutaneous coronary intervention) × 3, diabetes mellitus, chronic low back pain (L4-S1 disc bulge), chronic obstructive pulmonary disease on home oxygen, hypothyroidism, borderline personality disorder, depression, anxiety, and cerebrovascular accident with residual symptoms. She presented to the emergency room with complaints of worsening low back pain, associated with bilateral lower extremity numbness. She also reports intermittent urinary incontinence and being unable to make it to the bathroom for bowel movements, as well as chest pressure. The patient reports falling on her back two months prior. Per medical records, she denies fever, chills, urinary retention, bowel incontinence, saddle anesthesia, lower extremity weakness/numbness, headaches, chest pain, shortness of breath, nausea, vomiting, abdominal pain, leg swelling, and recent travel or sick contacts. Habits: Illicit drug user.

The patient was admitted to the hospital for complaints of low back pain, lower extremity weakness, and numbness. However, MRI of the lumbar spine did not show evidence of high-grade foraminal stenosis. Inconsistency in medical documentation is noted: the patient was seen ambulating without any assistive device, which argues against significant lower extremity weakness. There was no evidence to support significant focal neurological deficits or cauda equina syndrome. Hospital management/treatment was conservative, without any surgical intervention. For most patients with acute low back pain, bed rest is not typically advised; however, patients are usually encouraged to perform activities as tolerated. Furthermore, she was hemodynamically stable on admission; there was no evidence of sepsis, change in mental status, acute respiratory failure, active hemorrhage that required blood transfusion, cardiac arrhythmia, severe heart failure, acute renal failure, and severe electrolyte abnormalities.

The proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.