Appeal type: Medical necessity
Decision: Upheld

Diagnosis Sickle Cell Anemia
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

This patient with a history of sickle cell anemia (hemoglobin SS disease) who presented for care with a severe progressively worsening headache and pain of the mid-chest, back and arms which failed treatment with acetaminophen with codeine at home. He presented to the emergency department (ED) with the pain, a blood pressure of 150/102, heart rate of 101, respiratory rate of 20 and 100% oxygen saturation on room air. He was tearful on exam, had 10/10 pain in the ED (mostly in the chest and upper arms). His bloodwork was remarkable for a hemoglobin of 8.5 and urine toxicology screen positive for cannabinoids. An electrocardiogram (EKG) was performed that showed an ectopic atrial arrhythmia. A computed tomography (CT) scan of the head and a chest x-ray were performed and were negative. He was given intravenous (IV) fluids, IV morphine and was admitted for further treatment and monitoring of his pain . It appears that he received a one-time dose of morphine in the ED only prior to admission. At the time of admission, his pain was rated at a 5/10, primarily in the arm and chest, and his vital signs improved to a blood pressure of 133/86 and heart rate of 81. The acute inpatient level of care for this patient is under review for medical necessity.
The requested health service / treatment of the inpatient stay was not medically necessary for this patient. While this patient received treatment in the ER with IV fluids and pain therapy, this treatment was quite limited with one dose of morphine. The patient only had limited care needs, a short stay in the hospital while continuing on fluids and pain medications, and no other interventions that could not also have been safely met at a lower level of care. This patient had no high-risk features to his status, had no respiratory issues, and no additional concerning physical exam findings.
This patient has a past medical history of sickle cell anemia, with presentation of a vasoocclusive crisis without other concerning symptoms or concerns. His blood counts were stable, and while he required pain medication and IV fluid management, this could also have been provided at a lower level of care . He was only given one dose of IV morphine in the ED prior to admission, which is less than is typically done at this setting. Most patents should received anti-inflammatory medication such as Toradol in addition to at least 2 doses of opioid therapy prior to making a decision to admit. He had no high-risk features noted on his imaging and while there were minor abnormalities on the EKG, this did not require a full admission to evaluate. He was clinically stable throughout the hospital stay, appeared to be at his baseline level of function, and had no concerning physical exam or evaluation findings. He only received a couple of doses of IV morphine during the following two days and did not get scheduled Toradol therapy. This patient did not meet the typical criteria required for acute admission related to his sickle cell disease. There was no concern for acute chest syndrome, he had no severe vaso-occlusive episode (his pain responded significantly to the one dose of morphine provided in the ED), no clear aplastic or hemolytic crisis, no increasing splenomegaly, and no elevation in the serum bilirubin. While he had pain, he required minimal pain management, and he had no specific concerns that could not have been safely met at a lower level of care.
Therefore, based on the clinical information provided for review and standards of care within the field, the admission for this patient was not medically necessary.