Appeal type: Medical necessity
Decision: Upheld

Orthopedic/musculoskeletal 
Inpatient Hospital 

Diagnosis: Back and hip pain 
Inpatient Hospital Stay. The insurer denied the Inpatient Hospital Stay 

The determination is upheld. 

The patient has a past medical history significant for sickle cell disease and a bilateral hip replacement who came to the emergency department with a five-day history of hip and back pain that was previously controlled with ibuprofen and Percocet. Apparently, the patient ran out of medication, and this led to an exacerbation of pain that became severe one day before his presentation. The patient stated that this pain was similar to previous episodes of sickle cell crisis. 

At the time of admission, the patient denied chest pain, shortness of breath, palpitations, fever, chills, abnormal sweats, abdominal pain, dysuria, nausea, or vomiting.
On the physical exam, the patient was in some distress because of the pain. He had good air movement and the lungs were clear to auscultation bilaterally. The cardiovascular exam demonstrated a regular rate and rhythm. The abdominal exam was unremarkable. The rest of the physical exam was also unremarkable. 
Laboratory evaluation revealed that the white blood cell count was 10.7, hemoglobin 11.2, hematocrit 32.1, and platelets 304. International normalized ratio (INR) was 1.2. Serum sodium was 137, potassium 4.1, chloride 105, bicarbonate (HCO3) 25, blood urea nitrogen (BUN) 7, creatinine 0.6, and liver function tests normal. The glucose was 103.
The patient was admitted to the hospital with a diagnosis of sickle cell pain crisis. The treatment included intravenous hydration, administration of intravenous morphine, and monitoring of hemoglobin, hematocrit, and lactate dehydrogenase (LDH). Since the patient's pain significantly improved, and he remained afebrile and hemodynamically stable, he was discharged home. The inpatient stay was not medically necessary. 

According to the Principles and Practice of Hospital Medicine book, "Painful episodes are the most frequent complication in sickle cell disease. Patients who have had recurrent episodes may be treated at home with oral analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or opiates). If the episode is more severe, they may require higher-dose therapy in a hospital-based setting. Severe pain requiring repeated doses of IV analgesia is best treated as an in-patient. Other supportive care should include judicious administration of intravenous fluid. Supplemental oxygen is indicated if the peripheral capillary oxygen saturation (SpO2) or oxygen saturation (SaO2) are low. Painful episodes may take several days to a week or more to resolve. Other indications for admission include acute chest syndrome, sepsis, stroke, and hyperhemolysis. These complications are best managed in an intensive care setting." 

In this clinical case, the patient's pain was controlled with oral pain medications until the patient ran out of them. At the same time, this patient was afebrile and hemodynamically stable, there was no evidence of acute chest syndrome, sepsis, stroke, aplastic crisis, or any other clinically significant complications associated with sickle cell crisis. During the entire hospital stay, the patient remained afebrile and hemodynamically stable. 

There was no evidence that the patient had severe complications associated with a sickle cell crisis such as a stroke, seizure. There was no evidence that the patient had infiltrates on a chest x-ray associated with significant hypoxemia. There was no chest pain or tachypnea, acute peripheral ischemia, splenic or hepatic sequestration. 
This patient did not require any surgical intervention or exchange transfusion. There was no evidence that the patient's pain was not controlled during the observation period, and the patient did not require administration of parenteral pain medications via patient controlled analgesia (PCA). 

Taking into consideration all of this information, the patient did not require admission at the acute inpatient level of care.