Diagnosis: Low back pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient had an acute episode of low back pain without antecedent trauma. The patient does have a history of epilepsy. The patient's spine x-rays were negative. The patient was given Toradol, Diazepam and Tylenol during admission. Inflammatory markers were elevated. The health plan denied the admission.

The patient did not have Red Flag symptoms and was not administered intravenous opiates. Clinical practice guidelines1 do not support admission absent Red Flag symptoms.

Casazza2 reviewed symptoms (Red Flags) that should prompt aggressive treatment. The patient did not have any of these:

"Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required."

The in-patient hospital admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient admission is not substantiated.