Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease.

Treatment hospital admission.

The insurer denied coverage for hospital admission.

The denial is upheld.

This patient had sickle cell, a history of cerebrovascular accident (CVA), pulmonary embolism (PE), and on Xarelto, who was admitted for pain. The patient's pain improved, and she was discharged. The insurer has denied coverage for the hospital admission as not medically necessary.

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient, as the denial of the hospital stay was appropriate.

The emergency department (ER) note seems to say that the patient stopped taking their medications four days before the admission, including hydroxyurea and Dilaudid. If so, it was sufficient to restart them and discharge. Subsequent ER notes say, however, that "Pt [patient] reported that she has been taking her home 4mg [milligrams] Dilaudid and Tylenol with minimal relief." A computed tomography (CT) was ordered to exclude pulmonary embolism (PE), and was admitted. The discharge notes say that the pain was controlled with Dilaudid. It appears that it was dated prospectively. Based on the description, a computed tomography (CT) available already, and notes other notes stated that the patient could have been admitted to observation level on oral meds, and then discharged.      

The hospital admission was not considered medically necessary for this patient. As stated above, an observation level of care would have sufficed.

"Sickle cell disease (SCD) is a group of inherited red blood cell disorders affecting ... SCD results in anemia and "sickle cell crisis" (SCC). The main clinical feature of sickle cell disease is the ''acute painful crisis,'' which often requires hospitalization. The term "sickle cell crisis" is used to describe several acute conditions such as the vaso-occlusive crisis (acute painful crisis), aplastic crisis, splenic sequestration crisis, hyperhemolytic crisis, hepatic crisis, dactylitis, and acute chest syndrome. Other acute complications include pneumonia, meningitis, sepsis and osteomyelitis, stroke, avascular necrosis, priapism, and venous thromboembolism...Rapid pain assessment and initiation of analgesia should be undertaken promptly. Depending on the degree and severity of pain, analgesic administration can be given intravenously (IV) or intranasally. For patients who are not in severe pain and can tolerate oral medications, oral analgesics can be used. Generally, the type, route, and dose of the analgesic should be individualized to the patient." (Borhade , M. B., & Kondamudi, N. P. 2021).

In general, the optimal treatment of both acute and chronic pain requires an individualized approach that involves interdisciplinary care. This approach encompasses pharmacological, nonpharmacological, and integrative therapeutic interventions that are tailored to individual patient needs. There is no one-size-fits-all approach to optimal pain management. In the context of SCD, this interdisciplinary team includes providers from hematology, pain medicine, psychology/psychiatry, emergency medicine, nursing, and physical therapy among others." (Brandow, A. M. et al. 2020).

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.