Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell hemoglobinopathy
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This is a male with sickle cell hemoglobinopathy, who was sent to the emergency room (ER) for fever and body aches. The patient was admitted, given antibiotics, fluids, and improved. The patient was then discharged the following day. The request is for approval of the inpatient hospital admission.

According to the Milliman Care Guidelines (MCG Pediatric), inpatient admission is indicated as medically necessary for Sepsis and Other Febrile Illness, without Focal Infection by ANY ONE of the following: 
Neonate 28 days or younger with temperature of 100.4 degrees F (Fahrenheit) (38 degrees C (Celsius) or greater
Hemodynamic instability
Temperature greater than 103.1 degrees F (39.5 degrees C) (oral) that cannot be reduced by outpatient, emergency treatment, or observation care
Altered mental status that is severe or persistent
Seizure in child older than 5 years
More than 1 seizure within 24 hours
Fever persistence for 5 days or more
Finding (e.g., abnormal cerebral spinal fluid, bacteremia, physical examination abnormality) that prompts suspicion or diagnosis of specific infection requiring hospitalization (e.g., meningitis, pneumonia)
Failure of outpatient treatment as demonstrated by one or more of the following:
Insufficient improvement (or worsening) of signs or symptoms despite compliance with appropriate outpatient regimen of sufficient duration
Inability to adequately comply with appropriate outpatient regimen (eg, vomiting, altered mental status, inadequate outpatient or caregiver support)
Inability to tolerate outpatient regimen (e.g., severe side effects, allergy)

Inpatient admission required rather than observation care because of 1 or more of the following:
Specific infection identified that is too severe for outpatient treatment or observation care trial
Metabolic disorder (e.g., hypoglycemia, hyperglycemia, metabolic acidosis) that is severe or persistent 
Toxic clinical appearance in child persists without identified cause
IV (intravenous) fluids required rather than oral rehydration to replace significant ongoing (e.g., for greater than 24 hours) losses (greater than 3 L (liters)/m2 (meters squared) per day) 
Supplemental oxygen or respiratory treatments for over 24 hours that are performable only in acute inpatient setting 
Parenteral nutrition regimen need that must be implemented on inpatient basis
Parenteral antimicrobial regimen that must be implemented on inpatient basis (eg, infusion or monitoring needs beyond capabilities of outpatient parenteral therapy)
Strict or protective (e.g., laminar flow) isolation
Other condition, treatment, or monitoring requiring inpatient admission."

This patient could have been managed in a lower level of care, such as observational status on the date of service (DOS) in question. The patient had generalized pain, was treated for fever, was hemodynamically stable, and was discharged the next day. The patient would be able to receive intravenous (IV) antibiotics and fluids, and analgesics in observational care. 

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 did act reasonably and with sound medical judgment and in the best interest of the patient.

Based on the above, the insurer's denial is upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.