Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient Stay
The denial is: OVERTURNED in whole

This case involves a male with sickle cell anemia who presented to the hospital with complaints of pain due to presumed sickle cell crisis. Symptoms started the night before arrival. Attempts at controlling the pain with naproxen 500 milligrams (mg) were not successful. The pain is generalized. The patient is chronically on hydroxyurea, Endari, as well as folic acid. He complains of shortness of breath, cough, nausea as well as some fevers. There are no reports of sick contacts. He is not allergic to any medications.

The patient was admitted to the hospital to rule out sepsis. He received intravenous (IV) ceftriaxone, 2 mg of IV Dilaudid, and 1 liter (L) of normal saline bolus in the emergency department. Blood cultures, urine culture, were obtained. The lactate level was ordered. Hematology oncology, as well as an infectious disease, were consulted to assist.
The following day, the patient is feeling overall better. On review of systems, he denied headaches or vision changes. He continued to have some slight arthralgias and slight myalgias. The exam was unchanged. Vital signs remained stable; the patient was afebrile. Repeat laboratory studies show a white blood cell count decreasing to 12.2, hemoglobin of 6.8. Total bilirubin was elevated at 16.2, with an indirect portion of 13.5. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were both elevated at 123 and 61. The lactate was normal at 0.8. Antibiotics were stopped, and it appeared, he was improving.
The patient reported on morning rounds that his pain was manageable at 3 out of 10 and primarily in the lower back and hip. He can ambulate and tolerating diet well. Blood cultures remained negative. The worsening anemia was considered to be dilutional; the rate of normal saline infusion was decreased to 100 mL/h. The risk of blood transfusion outweighed the benefits of the current hemoglobin. Therefore blood transfusion was not provided.
Pain management consult was obtained on this day as well, who provided changes to the dosing of the analgesics.
The following day the patient reported that the low back pain and hip pain was reappearing. His temperature (T)-maximum was 100.1, and the rest of the vital signs were stable. Repeat labs were not available on this day. Blood and urine cultures remained without growth. The patient complained of a headache, which raised the possibility of meningitis. Neurology was consulted and recommended obtaining head computed tomography (CT). The patient did not have any focal neurologic deficits on the exam. The head CT showed no intracranial hemorrhage mass-effect or infarct. The neurologist concluded that the headache was associated with a sickle cell crisis. The treatment was continued with folic acid, hydroxyurea, IV fluid hydration, IV Toradol, and IV Dilaudid.
The following day, the patient's hemoglobin dropped down to 6.1 oxygen saturation, declined to 88-92%, and requiring nasal cannula oxygen with mild shortness of breath. Blood transfusion was offered to the patient but due to prior severe reactions after blood transfusion, he declined.
The patient was reassessed by hematology, and hemoglobin was repeated, which showed a value of 6.4 g/dL. Vital signs remained stable. White blood cell count improved to 11.5. He was cleared for discharge per hematology. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole.

The requested health service/treatment of inpatient stay is medically necessary for this patient. This patient has sickle cell disease, presenting with pain, but at the same time satisfies SIRS criteria for possible systemic infection. It was appropriate to admit the patient under an inpatient setting to rule out acute infectious causes. Initially, the patient did not require any oxygen, but on 10/3/2019 the documentation indicates a pulse oximetry of 87% on 2 L nasal cannula, with a hemoglobin of 6.8. These findings qualified the patient for inpatient hospitalization rather than the lower level of care.