Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell anemia
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld   
The patient with a history of sickle cell anemia who presented to the emergency department on with a history of vaso-occlusive crisis (VOC) with pain in the left upper arm and lower back. The patient received pain medications and was admitted for further management. Hemoglobin was 8.5. The patient improved and was discharged the next day.

The patient was admitted for pain and received pain management. The patient had a stable hemoglobin and did not have any documentation of complications of sickle cell anemia requiring inpatient hospitalization such as stroke, acute chest syndrome, sepsis or priapism. The patient could have been safely managed at a lower level of care. Therefore, the inpatient hospital stay is not considered medically necessary for this patient.

Du, S., Lin, C., & Tao, Y. X. (2019), "Sickle cell disease (SCD) is one of the most common severe genetic diseases around the world. A majority of SCD patients experience intense pain, leading to hospitalization, and poor quality of life. Opioids form the bedrock of pain management, but their long-term use is associated with severe side effects including hyperalgesia, tolerance and addiction. Recently, excellent research has shown some new potential mechanisms that underlie SCD-associated pain... The most common complication in patients with SCD is an acute pain episode[14]. Sickle blood cells often get stuck in small blood vessels, resulting in tissue ischemia/inflammation and consequently leading to clinical symptoms such as pain. SCD-associated acute pain is generally sharp, throbbing, or both. The severity and duration of pain between episodes vary among SCD patients[14]. Historically, acute pain episodes were considered to be due to acute vaso-occlusive episodes, called "crises"[15]. More recent studies, however, revealed that the causes of acute pain episodes included more complicated multi-cellular processes, such as interactions of sickled cells with the vascular endothelium and contributions from macrophage, mast cell, and platelet activation[16]. Thus, the recommended updated diagnosis is acute SCD pain[17]."

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." 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital stay is not substantiated.