Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell Anemia. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 
The denial is overturned. 

The patient is a female with a history of sickle cell disease, hemochromatosis, polysubstance abuse, and bipolar disorder. She presented to the emergency room (ER) with complaints of back and rib pain. The patient reported taking Percocet at home with no relief. The patient presented to the hospital with a one-day history of body aches, rib pain, back pain, fevers, chills, and productive cough for one day. The patient reported that her pain was primarily in her entire back and ribs. The patient's pain was a nine out of ten on a zero to ten pain scale. The patient reported her symptoms worsened the morning of presentation when she woke up shivering. The patient reports no alleviating or exacerbating factors. The patient's pain was moderate in severity, non-radiating, and constant. In the Emergency Department (ED), pertinent lab values included a white blood cell (WBC) count elevated to 27.3, elevated procalcitonin to 0.11, elevated reticulocyte count to 7.11, elevated lactate dehydrogenase (LDH) to 301, as well as elevated total bilirubin of 3.5. 

The Discharge Documentation shows the patient has the diagnoses of hemoglobin SS (sickle cell anemia) disease, hemochromatosis, polysubstance abuse, bipolar disorder, anxiety, and insomnia. The patient also reported that she had Percocet at home, but it no longer helped in alleviating her pain symptoms. The patient also reported fever, chills, cough, and cough is productive of yellow colored phlegm. The patient's pertinent vital signs included a temperature elevated to 101.3 and a blood pressure of 95/56. There was concern for infection in the setting of acute sickle cell pain crisis necessitating admission for intravenous (IV) pain control and IV antibiotics. The patient left against medical advice (AMA). 

This patient had a fever to 103 degrees Fahrenheit on admission with concern for an underlying infection and sepsis as the cause of her symptoms. This would warrant acute level hospitalization for management. This is no longer considered an uncomplicated pain crisis and would be considered a complicated pain crisis. While the etiology of her fever and potential infection was never discovered on admission there was enough concern to justify an acute hospital evaluation for management of this individual with a WBC of 27, fever, with cough with productive sputum. Unfortunately, she left against medical advice (AMA) prior to this being completed. 

"Conclusions: In febrile patients with sickle cell disease (SCD), WBC, absolute neutrophil count (ANC), and absolute band count (ABC) are all independently associated with bacteremia when adjusting for height of fever and age. Hematologic variables may be useful in developing prediction algorithms to identify febrile patients with SCD at higher risk of bacteremia. These data emphasize the need for a national trial to develop a predictive model with defined thresholds." (West, et al., 2002) 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.