Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease with hip and shoulder pain
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male. He was hospitalized related to sickle cell disease with hip and shoulder pain. The Milliman Care Guidelines (MCG) 25th edition criteria were not met and therefore the hospitalization was not felt to be medically necessary but rather the patient could have been treated on an observation basis. An appeal by Montefiore Hospital stated that the inpatient hospitalization was thought to be medically reasonable for this patient with sickle cell disease. It was stated that the patient had presented with painful crisis symptoms that were severe with worsening of bilateral legs, right hip, left hip, and bilateral upper extremity. The pain was not controlled with home medications. Treatment was noted to have included intravenous fluids, opioid management, imaging and monitoring of labs. The patient noted previous issues associated with aplastic anemia, splenic infarct as well as asthma, and chronic obstructive pulmonary disease (COPD) and issues of back and leg pain that have been uncontrolled with his home opioid regimen. The patient's blood pressure was 100/64, pulse was 75, and oxygen saturation was 99%. It was felt the patient was uncomfortable with pain at an eight out of ten. Hydromorphone was provided along with Benadryl and intravenous fluids. Per the physicians' recommendations, the patient was admitted to the inpatient setting for further management of shoulder, hip, and knee pain and significant uncontrolled pain with possible acute worsening. 

The proposed inpatient hospital admission was not medically necessary.
The decision to admit the patient was made by the treating physician who had the ability to assess the patient's clinical stating "initial aggressive management and way of a multitude of variables. Inpatient discharge summary noted the main diagnosis for hospitalization was acute on chronic pain in the setting of vaso-occlusive condition versus arthritic pain. Consultations while inpatient stated "given frequency of missed Ortho appointments, consulted Ortho for inpatient evaluation, recommended for outpatient evaluation." Clinical orthopedic exam of the right shoulder revealed nontender to palpation, no effusion, erythema, passive and active motion limited to 90 degrees abduction on the right. There was full motion of the left knee, it was nontender to palpation without effusion or erythema; the right knee had very limited motion of 15 degrees with pain on flexion. Principal diagnoses were chronic pain right knee, chronic shoulder pain, sickle cell disease, chronic. Treatment was deferred to outpatient management. Home medications included oxycodone 20 milligrams every four hours with Tylenol. The patient was hemodynamically stable and was felt to be safe to discharge with immediate follow-up.

Observational status was reasonable to be provided with assessment to ensure that there is no significant acute issues present for which an inpatient setting would be medically necessary. Of particular note was the fact that inpatient setting was used because it was difficult to get orthopedic outpatient visits and therefore orthopedics was consulted. In addition this individual had been discharged to a pain management program as was noted within the documentation reviewed and recommended through the criteria for the Official Disability Guidelines for outpatient pain management. There were no clinical findings that were unstable to the degree that would require inpatient setting. Pain medication was not altered on discharge. Upon presentation to the emergency department, the patient was provided with hydromorphone, appropriate pain management and therefore observational status for the management of the acute exacerbation of pain would be reasonable without the need for the inpatient setting.