Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute chest syndrome (ACS)

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient has a history of sickle cell anemia, who presented to the emergency room (ER) with complaints of a 3-day history of fever, cough, and occasional chest pain. A chest x-ray (CXR) revealed persistent upper lobe consolidation. Ceftriaxone and Azithromycin were started for community acquired pneumonia versus acute chest syndrome (ACS). The patient was admitted. She was continued on 500 milligrams (mg) of intravenous (IV) Azithromycin a day (QD) and 2000 mg of IV Ceftriaxone QD. Blood cultures revealed no growth. Hemoglobin (hgb) level dropped to 6.1. One unit of packed red blood cells (RBC) were given. Hgb level increased to 7.5. The patient was discharged with instructions to complete 2 more days of Augmentin and Azithromycin.

According to Friend, A., & Girzadas, D., "Acute chest syndrome (ACS) is the result of various inciting events causing vaso-occlusion within the pulmonary vasculature of patients with sickle cell disease (SCD). ACS can occur in any SCD phenotype. However, it is most common in HbSS (SCD genetype). ACS can progress quickly and is the most common cause of death in patients with SCD. Therefore, it is important to make the diagnosis and begin treatment as soon as possible."

Per Simon E., et al., "SCD patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition."

Per Guidelines and Protocols Advisory Committee, "Management of patients with definite ACS Admit and immediately treat patients with new ST (interval on ECG [electrocardiogram) segment elevation or new LBBB (left bundle branch block) and a history compatible with ACS, with the intent of re-establishing perfusion. [1] Admit and immediately treat patients with a history and ECG (without ST segment elevation) compatible with ischemia, plus either elevated cardiac biomarkers (> [greater than] 99th percentile) or hemodynamic compromise (hypotension or electrical instability), for acute myocardial ischemia."

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

The inpatient admission is considered medically necessary for this patient for possible chest syndrome versus other causes of chest pain. Based on a general impression, patient history, risk factors, electrocardiogram (ECG) and levels of myocardial infarction markers it is decided whether or not to admit the patient for clinical observation. In this case, the chest pain and x-ray findings raised the possibility of acute chest syndrome, a fatal complication, which requires admission. Therefore, the inpatient admission is considered medically necessary.

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.