Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease.

Treatment:  Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is upheld.

The is a patient with a past medical history of polysubstance abuse, vaso-occlusive sickle cell disease, aplastic anemia, splenic infarct, asthma, and chronic obstructive pulmonary disease. The patient presented to the emergency room with acute on chronic musculoskeletal pain to his bilateral knee, hip, right shoulder, elbow, and lower back. His labs showed a hemoglobin of 8.5, hematocrit of 25.2, BUN (blood urea nitrogen) of 30, bilirubin of 3.0, and a reticulocyte of 3.9. He was given intravenous (IV) fluids and opioids. X-rays showed unchanged osteoarthritis and avascular necrosis of the knees and shoulder from prior films, and is likely chronic. He was admitted and was treated with intravenous (IV) lactate ringers 1 liter, IV hydromorphone 1 milligram (mg) x 2, IV Benadryl 25 mg x 2, and IV normal saline 1 liter, but treated with his home regimen of oxycodone, lidocaine patches, and gabapentin.

The inpatient admission would not be considered medically necessary for this patient.

There is insufficient indication of the usual standards for admission such as seizures, stroke, persistently low blood oxygen levels, or bacteria in the blood. There was no chest pain that could signify chest syndrome. Labs were not appreciably worse than usual. Retic count indicated that he was keeping up with the peripheral destruction that was taking place due to sickling. The patient had avascular necrosis in both shoulders and pain. Per the x-ray, the patient had unchanged osteoarthritis and avascular necrosis of the knees and shoulder from prior films, and was likely chronic. He was admitted and treated with an IV but was treated with his home regimen of oxycodone, lidocaine patches, and gabapentin. His oxygen (O2) remained stable, and he had no chest pain to consider Chest Syndrome. There was no priapism, especially with a history of drug abuse, opioids were not increased. There appears to have been no need to admit him beyond initial hydration. Therefore, the request for an inpatient admission would not be considered medically necessary for this patient.

Brandow, A. M., Carroll, C. P., Creary, S., Edwards-Elliott, R., Glassberg, J., Hurley, R. W., Kutlar, A., Seisa, M., Stinson, J., Strouse, J. J., Yusuf, F., Zempsky, W., & Lang, E. (2020), "The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery. Conclusions: Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions."

Friend, A., & Girzadas, D. (2021), "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 (sickle hemoglobin). 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."

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      
                                                 
The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical Necessity is not substantiated.