Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Crisis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.  

This male patient has a history of sickle cell disease and presented to the Emergency Room (ER) from his pediatrician's office for his complaints of chest and left arm pain for one day. The patient rates his pain to be 7 out of 10, in severity. The patient took oxycodone at home but received no relief. The patient's reticulocyte count was 10.6%, and there was concern for vaso-occlusive crisis versus acute chest syndrome. The patient received intravenous (IV) fluid hydration in the ER and received IV morphine. The patient's pain decreased to about 4 out of 10 in severity. The patient was told to continue 1500 mg of hydroxyurea on weekdays and 1000 mg of hydroxyurea on weekends. The patient was to take 1 mg of folic acid a day. There were no unstable vital signs or low oxygen levels. The patient did not have a stroke, seizure, abnormal chest x-ray, kidney failure, or bacterial blood infection.

Per Borhade, et al (2019), "Rapid pain assessment and initiation of analgesia should be undertaken promptly. Depending on the degree and severity of pain, an analgesic administration can be given intravenously (IV) or intranasally. For patients who are not in severe pain and can tolerate oral (PO) 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 mg/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 hrs (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. If the pain is controlled, the patient may be ready for discharge with a home care plan and oral analgesia. 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. Simple or exchange transfusion may be warranted... The key is rapid hydration and pain control. In addition, oxygenation should be monitored. It is important to find and treat the trigger of the crisis to prevent a recurrent crisis."

As per the MCG (Milliman Care Guidelines) for Sickle Cell Disease, inpatient admission is medically indicated for acute chest syndrome, acute vaso-occlusive episode, and aplastic crisis, dehydration unresponsive to oral hydration, intractable pain, neurological deficit, splenic or hepatic sequestration, and concern for infection. In this case, this patient was documented to have intractable pain secondary to clinical sickle cell crisis requiring IV opiate medications for pain control. Therefore, inpatient level of care was medically necessary as it met the MCG criteria for inpatient admission.    

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity is substantiated. The carrier's denial of coverage for the inpatient hospital admission should be overturned.