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

The patient is a female with a 5 week history of L (left) buttock and leg pain. She had associated numbness and decreased foot strength as well. PSH (past surgical history) was significant for prior L (lumbar)5/S (sacral)1 micro-lumbar decompression.

An inpatient hospital admission was not medically necessary. Although the patient had slow progress with physical therapy (PT), this could have been provided at a lower level of care than inpatient. She does not meet inpatient criteria. The standard of care is to perform this procedure as an outpatient procedure. Inpatient stay may be needed for older patients, dural tear, hemorrhage or nerve root injury. None of these circumstances occurred in this patient. The health plan's determination is upheld.