Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease, pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for asthma, sickle cell trait, and beta-thalassemia minor who presented to the hospital with generalized body aches, mostly in her back and  legs. The symptoms started two days before the admission and were typical for her sickle cell pain. The patient gave a history of a subjective fever and chills, a runny nose, and cough. The patient stated that she took her oxycodone without significant relief of the symptoms, therefore, she decided to come to the emergency department. It was reported that the patient was recently hospitalized in a different facility where she received treatment with intravenous fluids and Dilaudid. Her clinical condition improved at that time, and she was discharged home.
The admitting physician stated that when the patient was in the emergency department she was hemodynamically stable.
At the time of admission, the patient was afebrile. The blood pressure was 112/65, pulse rate 85 beats per minute (bpm), respiratory rate 18 breaths/minute, and oxygen saturation 98% on room air. The patient was a well-developed, well-nourished individual who was resting comfortably in no acute distress. She had mild tenderness over her lower back. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft and non-tender to palpation, with normal bowel sounds, without guarding or rebound. She had mild tenderness in both shins. The neurological exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 12.2, hemoglobin 12.6, and platelets 124. Her sodium was 140, potassium 4.1, chloride 109, bicarbonate 24, blood urea nitrogen (BUN) 7.0, creatinine 0.58, and glucose 89. A chest x-ray revealed no evidence of acute disease.
The patient was admitted to the hospital with a pain crisis that was attributed to a viral infection. She received treatment with intravenous Dilaudid. The patient also received intravenous fluids and was recommended to utilize the incentive spirometer.
In the hospital, the patient was seen by a hematologist who stated that the patient's laboratory evaluation was not indicative of ongoing hemolysis. The pain was subjective and hard to quantify. The hematologist had a low suspicion for a sickle-cell emergency. At the same time, the hematologist recommended the continuation of treatment with folic acid and hydroxyurea. The hematologist also encouraged the use of incentive spirometry. There were no indications for any simple or exchange transfusion at that time.
During the hospital stay, the patient underwent laboratory evaluation that was not consistent with a hemolytic crisis. She had a normal lactate dehydrogenase (LDH), reticulocyte count, and normal bilirubin. In addition, there was no drop in the patient's hemoglobin and hematocrit (H&H) during the hospitalization. In the hospital, the patient's clinical condition improved, and she was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The review of the medical records revealed that there was no objective evidence that the patient in fact had a sickle cell crisis. As it was noted by the hematologist, the patient's pain was subjective and was disproportional to clinical findings. The review of the medical records demonstrated that the patient did not have acute chest syndrome associated with new alveolar infiltrates, chest pain, hypoxic, tachypnea, wheezing, cough with sputum production. There was no evidence of central nervous system involvement. The laboratory evaluation did not reveal significant hemolysis or aplastic crisis. The patient did not need any emergent surgery. Taking into consideration all of this information, there is not overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care. A lower level of care to rule out sickle cell crisis and ensure clinical stability was appropriate.

Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.