Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient presented due to a headache and was treated with a fluid bolus with acetaminophen. The patient was admitted, for that headache, but was discharged the next day. The medical records indicate the patient has a history of sickle cell anemia. The documentation does not show that the patient had neurologic changes consistent with a stroke. There was no evidence of acute chest syndrome (ACS); such as symptoms of high fever, rapid breathing, shortness of breath (SOB) or tightness in chest, nor did the patient have signs of sepsis that would require inpatient hospital care. 

The patient presented with a headache and was treated with Tylenol and a fluid bolus. The medical records do not document any neurologic changes concerning for a stroke. There are no other documented complications of sickle cell anemia such as acute chest syndrome or fever. The patient has no other documented co-morbidities. The patient could have been safely evaluated and managed, for their headache, at a lower level of care. 

"The diagnosis of ACS depends on both radiographic evidence and clinical symptoms. To be diagnosed with ACS, a patient must meet the following criteria. New pulmonary infiltrates on chest imaging (chest x-ray, CT) involving at least one lung segment; this cannot be due to atelectasis and must have one of the following symptoms:
-	Chest pain
-	Temperature more than 38.5 degrees C
-	Tachypnea, wheezing, rales, coughing, appearance of an increased work of breathing
-	Hypoxemia, relative to baseline (more than 2% decrease in oxygen saturation from steady state on room air)." (Friend, A., et al., 2023).

"Sickle cell disease (SCD) is a devastating disease that affects approximately 100,000 individuals in the United States, most commonly blacks. Individuals with SCD often experience multiple life-threatening complications during their lifetimes. Given the progressive nature of SCD, individuals increasingly rely on emergency department (ED) care as they age. The most common reason for ED visits is acute painful vaso-occlusive episodes, which require treatment with parenteral opioids; however, individuals with SCD may develop other serious complications, including acute chest syndrome and stroke." (Kavanagh, P. L., & Hirshon, J. M. 2020).

"Sickle cell disease (SCD) is one of the most common monogenetic diseases worldwide and is attributable to significant morbidity and mortality. Mutations causing abnormal hemoglobin formation in this disease lead to structural abnormalities and cumulative damage to the cellular membrane of sickled erythrocytes. Polymerization and aggregation of these cells within the microvasculature results in severe vaso-occlusive pain crisis, chronic hemolytic anemia, and multiorgan pathology in patients. Pulmonary manifestations of SCD, including the acute chest syndrome (ACS), are a leading cause of hospitalization and mortality. ACS is a severe type of acute lung injury, defined as the development of a new pulmonary infiltrate, involving at least one complete lung segment, that is accompanied by fever, chest pain, tachypnea, wheezing, or cough in a patient with SCD. The etiology of ACS is multifactorial, with the most common mechanisms including infection, fat and bone marrow embolism, and direct microvascular vaso-occlusion. Despite recent advances in our understanding of the pathogenesis and clinical management of ACS in SCD, patient outcomes remain unacceptably poor." (Sysol, J. R., & Machado, R. 2016).                                                         

Based on the above, the insurer's denial must be 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 admission is not substantiated.