Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Anemia requiring pain management

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Reversed

The insurer has denied coverage for inpatient hospital services. In their Final Adverse Determination letter they write that this is a patient with a history of sickle cell disease who presented with increasing bilateral elbow, wrist and knee pain. The patient's doctor asked for an inpatient hospital stay. To approve this service the following criteria must be met: The patient needed a change in the doctor's plan, the patient needed a worsening condition, and needed new symptoms.

An appeal letter states that this patient was appropriately admitted on an inpatient basis for the emergent management of sickle cell crisis that could not be safely managed in a lower level of hospital care or in an outpatient setting. Inpatient admission of this patient with sickle cell anemia requiring pain management was supported by guidance from the National, Heart, Lung and Blood Institute (NHLBI).

This patient has a history of sickle cell disease who presented with increasing bilateral elbow, wrist and knee pain in sickle cell crisis. The patient received a total of 9 doses of Hydromorphone. The patient signed out against medical advice (AMA). 

The health plan is denying admission. Borhade et al (1) published a review of the management of Sickle Cell Crisis and stated rapid pain assessment and initiation of analgesia should be undertaken promptly. Depending on the degree and severity of pain, analgesic administration can be given intravenously (IV) or intranasally. For patients who are not in severe pain and can tolerate oral medications, oral analgesics can be used. Generally, the type, route, and dose of the analgesic should be individualized to the patient. Most guidelines recommend early initiation of parenteral opioid analgesics, usually with morphine at 0.1 milligram (mg)/kilogram (kg) IV or subcutaneously (SC) every 20 minutes and maintaining this analgesia with morphine at doses of 0.05 to 0.1 mg/kg every 2 to 4 hours (SC/IV or PO). Those with persistent pain benefit from a patient-controlled analgesia (PCA) pump. Close monitoring of vital signs including oxygen saturation should be maintained with frequent reassessments of pain severity or resolution.[8] If the pain is controlled, the patient may be ready for discharge with a home care plan and oral analgesia.[9] If the pain is uncontrolled despite the above treatment plan, consider hospitalization and the use of stronger forms of analgesia or higher doses titrated to the patient's needs. A simple or exchange transfusion may be warranted.[10] tinzaparin has been found to shorten the course of pain. A randomized, controlled, double-blind study has suggested that the clinical effects of tinzaparin are due to its effect on cellular factors. No special monitoring is needed for once-daily dosing.[10] Adjuvant therapy includes hydroxyurea, antihistamines, anxiolytics, and antiemetics.[10] It is prudent to maintain adequate hydration and be vigilant in identifying other causes of pain that may need additional treatment."

American Society of Hematology (ASH) clinical guidelines specifically warn about "Doses >100 mg of morphine milligram equivalent (MME) is associated with a ninefold increase in risk of overdose compared with doses <20 mg of MME in general non-sickle cell disease (SCD) pain populations."  This patient received 9 doses of Hydromorphone which are considered to be greater than 100MME.

The admission was medically reasonable and necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital services is substantiated.