Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic Diseases/Sickle Cell Disease/Vaso-Occlusive Pain due to Sickle Cell Disease.
Treatment: Inpatient Hospital Admission.
The health plan denied the requested inpatient stay as not medically necessary. T
he health plan's determination is upheld.

The patient is a male with a past medical history significant for HbSS (sickle cell disease), alpha thalassemia, acute coronary syndrome, cerebrovascular accident, avascular necrosis, priapism, and a history of previous episodes of vasa occlusive crisis who presented to the hospital with a 3-day history of right hip pain and back pain. The patient stated that the right hip and lower back pain were typical of his vasa occlusive crisis. When seen by the admitting physician he stated that his pain was sharp. He was unable to identify any trigger in this episode.
At the same time, he denied chest pain, priapism, shortness of breath, fever, chills, nausea, vomiting, abdominal pain, and dysuria. When seen by the admitting physician, the patient was afebrile. His heart rate was 92 beats per minute (bpm), with a respiratory rate 18 breaths per minute, a blood pressure of 126/81 millimeters of mercury (mmHg), and an oxygen saturation of 100% on room air.
The patient was a well-developed, well-nourished individual who was conversant and compliant with the examination. His lungs were clear to auscultation with no crackles, rhonchi, or wheezing. He had a regular rate and rhythm with no murmurs, rubs, or gallops. Peripheral pulses were symmetric and intact. The abdomen was soft, non-tender, and non-distended, with no masses or organomegaly. Bowel sounds were present. There was pain over the right trochanter but minimal tenderness to palpation on the exam. The patient also described band-like pain across the lumbar spine but without significant tenderness to palpation. The neurological exam was unremarkable.
An X-ray of the hips demonstrated grossly unchanged right femoral head avascular necrosis without evidence of bony collapse. There was no fracture or dislocation. The patient is status post total left arthroplasty.
The patient was admitted to the hospital with vasa occlusive crisis, avascular necrosis of the hip, and leukocytosis. The patient received treatment with intravenous fluids and intravenous pain medications.
According to the notes, the patient had no signs of active hemolysis. In the hospital, the patient received treatment with intramuscular Dilaudid every 4 hours. The patient's pain gradually improved, and he was transitioned to oral Dilaudid. By the end of admission, the patient was able to tolerate his pain only with oral pain medications. He was transitioned to outpatient care.
At issue is the medical necessity for the inpatient hospital admission.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient was admitted to the hospital with a vaso-occlusive crisis, however, there was no evidence that the patient had signs or symptoms of central nervous system injury including stroke, seizure, and posterior reversible encephalopathy syndrome.
There was no evidence that the patient had acute chest syndrome including newly diagnosed alveolar infiltrates. There were no complaints of chest pain, hypoxemia, abnormal breath sounds, persistent cough, or mucus production. There was no documented hypoxemia. The patient did not need any emergent surgery. There was no evidence of splenic or hepatic sequestration.
There was no mention of acute ischemia, acute renal failure, aplastic crisis, or priapism. There was no evidence of infection requiring inpatient treatment. There was no documented altered mental status. The patient was able to maintain oral hydration and did not need an exchange transfusion.

Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.