Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease
Treatment: Inpatient emergency admission
The insurer denied coverage for: Inpatient emergency admission
The denial is: Upheld.
The patient has a past medical history of sickle cell disease. The patient presented to the emergency department (ED) with a chief complaint of generalized pain associated with nausea, non-bloody, non-bilious (NBNB) emesis since this morning. Viral syndrome was suspected. The patient usually takes Dilaudid 2 milligram (mg) at home but ran out of their medication and could not refill it. The physical exam is unremarkable. The vital signs at presentation were stable. Patient states this feels like her usual sickle cell pain. The patient reports that used to go once a month, but last saw their provider a few months ago, and has not been able to get an appointment. Patient also states that they can no longer see that provider because he no longer takes their insurance, and also needs a new Hematologist.

This patient can be taken care of with hydration and provision of Dilaudid on the outpatient basis. The stated reason for admission was that the patient needed frequent vital signs, however vital signs were stable. Guidelines discourage admissions for routine sickle pain due to not taking pain medication (Borhade et al, 2019). Dilaudid is a short acting drug and pain control can be quickly re-established by restarting it. Hydration can be delivered on the outpatient basis. Therefore, the inpatient emergency admission is not medically necessary for this patient.

Telfer, P., & Kaya, B. (2017), "The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned. Pain management in the emergency department often does not meet acceptable standards, while chronic use of strong opioids is likely to result in opioid-induced hyperalgesia, exacerbation of chronic pain symptoms, and opioid dependency. We suggest that an integrated approach is needed to control the underlying condition, modify psychological responses, optimize social support, and ensure that health care services provide safe, effective, and prompt treatment of acute pain and appropriate management of chronic pain. This integrated approach should begin at an early age and continue through the adolescent, transition, and adult phases of the care model."                                                         

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 an inpatient emergency admission is not substantiated.