Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Anemia
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Overturned

The patient is a male with medical history significant for sickle cell anemia and glucose-6-phosphate-dehydrogenase (G6PD) deficiency that presented to the emergency department (ED) with two-day history of right hip pain. He had presented to the ED the day before, was treated and discharged on oral pain medication. Because he was still in a lot of pain, he was referred back to the ED by his pediatrician. He had chest pain the day before that had resolved. He was admitted for ongoing acute pain crisis. Admission orders included intravenous (IV) fluids at maintenance, regular diet, morphine as needed every four hours, Tylenol as needed for fever, Lovenox for deep vein thrombosis (DVT) prophylaxis, and Hematology consultation. Ceftriaxone was added due to fever, with negative pending cultures. Testing returned positive for influenza A, so antibiotics were discontinued, and he was treated with Tamiflu. He was also treated with his routine home medications. He remained on intravenous (IV) fluids, tolerated his regular diet, and was managed initially with morphine every four hours. He was transitioned to Percocet as needed on day two. By hospital day four, his pain had resolved. He was subsequently deemed stable for discharge to complete course of Tamiflu. The subject under review is the medical necessity for the inpatient stay.

After failing outpatient pain management, the requested acute inpatient stay was medically necessary.
Sickle cell anemia is a common genetic disease in which hemoglobin in red blood cells is replaced by an abnormal form, hemoglobin variation (S). This causes red blood cells to form sickling shapes that block small blood vessels. In addition, these red blood cells do not survive as long, causing anemia. As a result, multiple complications can occur, including chronic anemia, acute chest syndrome, vaso-occlusive (acute pain) crisis, splenic sequestration requiring splenectomy (increasing risk of infection and sepsis), dactylitis, stroke, generalized altered immune function with increased risk of bacterial sepsis, pulmonary hypertension, and renal disease. Evaluation and management of vaso-occlusive crisis are particularly problematic because patient presentation and reported severity of pain are oftentimes inconsistent or contradictory; reported severity should not be down-played or ignored. In addition, many patients have undergone splenectomy due to sequestration and thereafter remain at risk for sepsis particularly from encapsulated organisms such as Streptococcus. Any fever should be taken very seriously as it may be the only warning of impending sepsis and shock.
This patient presented with persistent leg pain despite opiate pain medications prescribed the day prior. Laboratory evaluation was not indicative of aplastic crisis, and pain management in the ED was beneficial. He was treated with morphine every four hours, transitioned to Percocet as his pain came under control. He was febrile in the ED, prompting evaluation for acute infection. Blood culture was negative but rapid influenza screen was positive for influenza A. He was treated with Tamiflu and antibiotics were discontinued. He was discharged upon resolution of his pain. This level of care following failed outpatient management was most consistent with acute inpatient management. Lower level of care would not have been appropriate in this case.