Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hereditary Spherocytosis.
Treatment: Inpatient Services. 
The insurer denied coverage for inpatient services. 
The denial is upheld. 

The patient is a male who presented for care with concerns of fever, vomiting, cough, and decreased inability to tolerate oral intake. His past medical history is significant for hereditary spherocytosis. On presentation to the emergency department, he was noted to have a temperature of 100.5 degrees Fahrenheit (F), heart rate of 163, respiratory rate of 22, and was noted to be pale with dry lips, icteric sclera, jaundice, erythematous tonsils, and splenomegaly. His labs were remarkable for a red blood cell count of 2.91, hemoglobin 6.9, and reticulocyte count of 11.4% [percent]. Urinalysis showed urobilinogen, and RVP (Respiratory Virus Panel) testing was positive for influenza A. Hematology was consulted, and recommended transfusion. However, the patient's mother declined transfusion, so he was given intravenous (IV) fluids, IV Zofran, Tylenol, and ibuprofen. He was admitted to the pediatric unit later that day, with diagnosis of fever and spherocytosis, and was started on Tamiflu. He was then transfused with red blood cells, with Benadryl given prior to transfusion, and his fever and nausea were managed with medications. He was still febrile to 102.9 degrees F, with a heart rate of 134, but his hemoglobin had improved to 7.8 after the 1 unit of packed red blood cells. He was given a second unit of packed red blood cells at this time. Later that day, he was cleared for discharge, and routine follow-up was scheduled. 

This patient has a diagnosis of hereditary spherocytosis and presented with findings of anemia in the setting of active influenza infection. He was noted to be tachycardic, and anemic with a hemoglobin of 6.9 on initial presentation. It is not clear what his baseline hemoglobin level is, and it is not clear if he has baseline splenomegaly. He was treated with 2 units of packed red blood cells, intravenous fluids, and Tamiflu. His hospital stay was less than 48 hours, and it is not clear why he was not placed in observation status. 

Hereditary spherocytosis is a hemolytic anemia that has different levels of severity. Without additional documentation, it is not clear how severe this patient's baseline diseases. There is mention of him receiving blood transfusions as an infant, but it is not clear if he requires frequent transfusion support. With the denial of his hospital stay, the appeal notes that he was considered to be immunocompromised. However, while he does have an enlarged spleen on physical examination, he is not considered to be immunocompromised, and does not require additional care based on this finding alone. Once his spleen is removed for the diagnosis of spherocytosis, he would then be considered immunocompromised from his condition. There is no clear documentation to show that he needed the aggressive inpatient level of care to support his condition. 

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

The insurer's denial of coverage for the inpatient services is upheld. Medical Necessity is not substantiated.