Diagnosis: Spinal Canal Stenosis, Spinal Disc Protrusion
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld.
This is a male patient is a male who was admitted to the hospital with complaints of chronic pain located in his lower back and down the right leg. The patient reports that he has been experiencing it for several months and it had worsened over the last several days; he rated the pain as 7/10 in severity. The patient had a schedule for surgery. The patient noted a slight increase in difficulty urinating and had constipation due to medications. On exam, the patient had a positive straight leg raise test on the left and decreased sensation along L5 and swelling to the right leg and 4/5 weakness of the right leg with decreased sensation in the calf and dorsum of the foot. He was admitted to the hospital for pain management and surgical intervention. The patient underwent an L4-5 right microdisectomy, medial facetectomy, foraminotomy and decompression of the nerve root without complications. The patient was medically stable and was discharged home in good condition.

Based on the review of the medical record, inpatient admission was not necessary for this patient according to the national policies including MCG Lumbar Discectomy, Foraminotomy or Laminotomy as they state the surgery is ambulatory or one day postoperative care. Inpatient is for non-elective or multilevel procedures or patients who need prolonged postoperative care. However, in this case, there is no evidence that this patient required every 4 hour intravenous medications or frequent neurological checks that warranted inpatient admission. The patient's care could have been managed at the observational level for pain control and imaging. The patient had no significant co-morbidities, did not require round-the-clock IV medications or steroids, and had no red-flag symptoms or severe findings on imaging to suggest cauda equina. Therefore, this patient's care could have been provided at a lower level of service.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.