Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemoglobin sickle cell (Hb-SS) disease. 
Treatment: Inpatient Stay. 

The insurer denied coverage for inpatient stay. 
The denial is upheld. 

The patient is a male diagnosed with hemoglobin sickle cell (Hb-SS) disease. According to the provider note, the patient presented to the Emergency Room (ER) with a painful venous occlusive crisis. The patient reported severe, progressive, worsening abdominal pain that is radiating to the bilateral knees. The patient's pain is associated with acute bilateral hand and elbow pain. The medical record indicates that the patient's symptoms were similar to his prior sickle cell pain crises. On initial presentation, the patient was severely hypertensive, blood pressure of 195/86 millimeters of mercury (mmHg). On examination, the patient had tenderness to palpation in the abdomen. Laboratory studies were remarkable for leukocytosis, white blood cell (WBC) count of 16.8 x 109/liter (L), severe normocytic anemia, hemoglobin 5.9 grams per deciliter (g/dl) with mean corpuscular volume (MCV) 86 femtoliters (fL), elevated reticulocyte count 12.5%, significantly elevated lactate dehydrogenase (LDH) of 1558 units per liter (U/L), hyperbilirubinemia, total bilirubin 2.9 milligrams per deciliter (mg/dl), and elevated creatinine of 2.16 mg/dl. The chest radiograph demonstrated cardiomegaly with pulmonary vascular congestion. The patient's computerized tomography (CT) scan of the abdomen demonstrated a small bowel hernia that was not obstructing and inhomogeneous bone sclerosis consistent with numerous areas of bone infarction from sickle cell disease. In the Emergency Department (ED), the patient was administered intravenous (IV) fluid hydration, IV morphine, IV ceftriaxone, and blood transfusion with one unit of packed red blood cells. The notes state that this was his classic typical pain crises. The patient's blood pressure (BP) was never reassessed or treated until transfer when it was noted to be 143/72. The patient was admitted to the hospital and given fluids and pain medications. The patient improved and was discharged uneventfully. 

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018) 

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021) 

This patient could have been managed in a lower level of care such as observational status on the date of service in question. The patient presented with an uncomplicated vaso-occlusive crisis (VOC). There was no evidence of neurological compromise, priapism, splenic sequestration aplastic crisis, cerebral vascular accident (CVA), acute chest syndrome, or other VOC related issue that would warrant acute level care. Uncomplicated VOC crisis do not warrant acute level care for management. While the patient did present with a one-time severely elevated BP, this was not a concern or addressed medically and therefore was not an issue. There is no documentation that there was concern for a hypertensive emergency. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient stay rendered is upheld. Medical necessity is not substantiated.