Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis (vaso-occlusive crisis)
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the proposed inpatient admission is not "medically necessary".

The patient is a male with medical history significant for ORIF (open reduction internal fixation) of a left tibia fracture the month prior that presented to the ED with one-day history of shortness of breath and chest pain. The pain awoke him from sleeping, and was exacerbated with deep breaths. He had no fevers, cough, or congestion. Additional history obtained following admission included presence of sickle cell trait. He took aspirin twice for the pain without improvement. The pain was described as sharp and constant, rated 10/10, located in the middle of his chest. 

Vital signs included temperature 36.8, heart rate 115, respiratory rate 20, blood pressure 104/68, and oxygen saturation 99% in room air. Examination was significant for no respiratory distress, no wheezing, no chest wall tenderness, intact distal pulses, left lower extremity in a cast from mid-thigh to ankle, no diaphoresis, and non-focal neurologic exam. Because of concern for pulmonary embolus, CT angiogram of the chest was ordered along with multiple lab studies and an electrocardiogram. The CTA was negative for pulmonary embolus but there was still the possibility of DVT (deep vein thrombosis). Laboratory evaluation was significant for leukocytosis (WBC count 10.20K with 80.3% neutrophils), mild anemia (hemoglobin 12.7), elevated alkaline phosphatase (151.0), elevated PT (prothrombin time) with normal INR (international normalized ratio) (14.1 and 1.19 respectively), normal troponin I, normal PTT (partial thromboplastin time), and elevated D-dimer (685). 

The patient was admitted for further evaluation and monitoring for possible DVT. Orthopedics was consulted to remove the cast so that an evaluation could be done. By the second hospital day his chest pain had resolved. The cast was removed and his leg was placed in a knee immobilizer. Doppler studies and x-rays were ordered, all negative. Repeat D-dimer was lower at 611. He was deemed stable for discharge home to follow-up in orthopedic outpatient clinic.

Patients that require lower limb immobilization following injury, either with bracing or casting, are at risk for development of deep venous thrombosis (DVT AKA VTE, venous thromboembolism). There is great variability in risk of thrombosis as well as variability in expected benefit from thromboprophylaxis. The use of thromboprophylaxis is extremely variable, with recommendations ranging from no patients to most patients. The evidence for usage of thromboprophylaxis with low molecular weight heparin in patients with lower limb immobilization, for example, is of low to moderate quality. In pediatric patients, DVT is relative rare, but can have the same serious sequelae as in adults (e.g. pulmonary embolism). If suspected, early identification and initiation of treatment is instrumental in preventing morbidity and mortality. 

In the case of this male patient, he had his left lower extremity immobilized for approximately a month when he developed sharp chest pain severe enough to awake him from sleep. While he did not have a pulmonary embolus on CT angiogram, there was concern that he had developed a DVT in his lower extremity. He was admitted for overnight monitoring, and upon removal of the cast, evaluation of the left lower extremity for DVT. All studies were negative, and his pain resolved without intervention. While it was reasonable to observe him overnight for evolution of his chest pain pending further diagnostic studies, he was overall stable. Pulmonary embolism had already been ruled out in the ED. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.