Diagnosis: Back pain.
Treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

This is a female with a history of chronic low back and left leg pain. She has had physical therapy, injections and medications without relief. She apparently was set up to have surgery. She presented to the emergency room (ER) and threatened suicide if she were discharged. The neurologic exam showed alternating weakness and normal strength of the left leg with an inconsistent exam. The lumbar magnetic resonance imaging (MRI) shows mild narrowing L (lumbar) 5-S (sacral) 1 left due to disc osteophyte complex. The provider recommended a lumbar discectomy L5-S1 left that was performed.

The inpatient admission was not medically necessary from the standpoint of her lumbar radiculopathy and subsequent lumbar laminectomy and discectomy. The procedure performed is an outpatient procedure, and therefore an inpatient admission is not medically necessary. It appears that the patient was having psychological issues and was also admitted for these reasons. Also, it appears that the patient had previously been denied surgery and was trying to have the procedure performed. Regardless, the procedure performed is an outpatient procedure and does not require an inpatient stay. A lower level of care would have been appropriate to address the patient's issues.