Diagnosis: Sacral Fracture.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned.

This was a female with history of spinal stenosis status/post (s/p) fixation and hemorrhoids who presented to the emergency department (ED) with complaints of coccygeal pain and constipation for a period of 9 days s/p fall from level ground. The patient reported difficulty with bowel movements since the fall with straining and bright red blood per rectum. She also reported difficulty urinating.

The inpatient hospital stay was medically necessary for this patient. Based on review of the available medical record, the inpatient admission was medically necessary. The patient was found to have a sacral fracture with urinary and bowel symptoms. Despite the patient being hemodynamically stable and the neurological examination being normal, the patient had acute urinary retention, which required foley catheter placement and appropriate specialty consultation.