Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Disease
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient has a diagnosis of Sickle Cell Disease (SCD) and presented to the emergency department (ED) for urgent evaluation of severe pain in the bilateral upper and lower extremities. The patient's pain started suddenly and has progressively worsened to the point it was at the level of nine out of 10 pain. The patient's labs demonstrated leukocytosis of 14.0, indicating stress or infection; the hemoglobin was low at 9.5 with a hematocrit of 28.1 percent (%). The lactate dehydrogenase (LDH), alkaline phosphatase, bilirubin, and reticulocyte count were elevated on admission; all were consistent with crisis. The patient was treated with intravenous fluids (IV), IV Dilaudid, and morphine while in the ED, which only contributed to some clinical improvement. Given the patient's pain was likely secondary to sickle cell crisis, as well as his low hemoglobin, the patient was then admitted to an inpatient level of care for further management of sickle cell anemia and sickle cell crisis, especially as the patient's pain was not controlled in the ED. 

The patient's admission was necessary due to the continued level of significant pain, the persistent elevated white blood cell (WBC) count, and the need for IV narcotics to control the pain.

"SCD and its related comorbidities and complications result in high acute health care utilization. In addition, vaso-occlusive crisis (VOC) remains the primary reason for SCD patients' ED visits and inpatient admissions." (Shah, N., et al, 2019)

"In spite of significant strides in the treatment of sickle cell disease (SCD), SCD crises are still responsible for high morbidity and early mortality. While most patients initially seek care in the acute setting for a seemingly uncomplicated pain episode (pain crisis or vaso-occlusive crisis), this initial event is the primary risk factor for potentially life-threatening complications. The pathophysiological basis of these illnesses is end-organ ischemia and infarction combined with the downstream effects of hemolysis that results from red blood cell sickling." (Novelli, et al, 2016)

"Sickle cell disease has no cure and is associated with life-threatening complications. Thus, the disorder is best managed by an interprofessional team that includes a hematologist, surgeon, pulmonologist, orthopedic surgeon, internist, dentist, nurse practitioner, and pharmacist. The key is patient education. By maintaining good health, getting vaccinated, and avoiding triggers, some patients can lead a decent quality of life. The outcomes for most patients are guarded, and sickle cell crises often require readmissions to the hospital. Many of these patients have chronic non-healing wounds, and hence a wound care nurse must be consulted. Overall, patients with sickle cell disease have a much shorter life span compared to the healthy population." (Sedrak, et al, 2021)

"Patients with SCD have higher rates of hospitalization and emergency department (ED) use than other groups, with ED utilization rates and cost rising with age." (Jacob, S. A., et al, 2020)                                                         

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.