Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Other/Status Post Hip Replacement/Sickle Cell Disease without Crisis, Acute Blood Loss Anemia Requiring Transfusion.
Treatment: Inpatient Hospital Admission.
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with a history of sickle cell disease (SS), and avascular necrosis of the left hip, who presented to the hospital for a hip replacement. He arrived at the hospital the day before the procedure to allow for appropriate rehydration and clinical management. He had the surgical procedure performed following his overnight hydration. Postoperatively, he was noted to have a hemoglobin of 7.2, and he was treated with a packed red blood cell transfusion. His postoperative pain was managed with scheduled Toradol, scheduled intravenous (IV) Morphine, and Tylenol. He was transitioned to oral Hydromorphone and Ibuprofen. Follow-up hemoglobin testing the next day showed a hemoglobin of 7.9, and he was discharged home with close outpatient follow-up.
The acute inpatient level of care is under review for medical necessity.

The health plan's determination is overturned, in whole.

This patient was admitted for perioperative care related to a hip arthroplasty performed in the setting of avascular necrosis caused by sickle cell disease. When looking at the Milliman Care Guidelines (MCG) policy for operative status for this procedure, an ambulatory procedure may be appropriate in those selected patients undergoing a primary unilateral elective procedure, or without active or unstable comorbidities that significantly increased risk or require prolonged postoperative monitoring, and to receive appropriate perioperative clinical care and support. Inpatient stays are appropriate for those undergoing nonelective, bilateral or revision procedures, patients with comorbidities that require more prolonged postoperative treatment or monitoring, and patients without sufficient outpatient care and support to allow early outpatient recovery.
In this situation, the patient has an underlying condition of sickle cell disease. It is standard of care for surgical procedures in the setting of sickle cell for patients to receive appropriate preoperative hydration, and/or red blood cell transfusion. This hydration and transfusion (when necessary) can prevent significant sickle cell crises following the stress of a surgical procedure. As this patient's preoperative hemoglobin was at 10, preoperative transfusion was not necessary, but he was appropriately hydrated with intravenous fluids. Postoperative hydration and/or transfusion is also necessary in this setting, to prevent significant sickle cell crises. In this case, the patient had a postoperative hemoglobin of 7.2, and packed red blood cell transfusion was appropriately provided. Further monitoring was necessary to ensure that his hemoglobin remained stable, and that he was safe for discharge home.
This patient is considered to have a comorbidity that requires more prolonged postoperative treatment or monitoring. The criteria for inpatient stay surrounding the hip arthroplasty are met per the MCG policy. Therefore, this request for an inpatient stay should be approved as medically necessary.