Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic Diseases-Sickle Cell Disease. 
Treatment: Inpatient Hospital Stay. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

This patient is a female to male, who was admitted for a diagnosis of sickle cell crisis. The patient presented with low back and bilateral leg pain. The patient was taking Percocet 10 milligrams (mg) every four hours at home without relief. 
His vital signs demonstrated a temperature at 97.3 Fahrenheit(F), pulse was 90, respiratory rate was 18, blood pressure was 114/72 and pulse oxygen (O2) saturation was 95%. His physical exam showed the patient resting in bed with a blanket over his head. There was no altered mental status. There was tenderness to palpation over the lumbar paraspinal muscles. 

His white blood cell count was 10.3 with a hemoglobin at 7.5. His lactate dehydrogenase (LDH) was 431. The patient was treated with pain medications including intravenous (IV) morphine 4 mg every four hours with little relief and was changed to 6 mg every four hours. The patient reported his pain continued at an eight out of 10. The patient was documented as sleeping and having boisterous conversations over the phone.
IV morphine was discontinued, and he was able to be switched to his home dose of oxycodone and was discharged. 

At issue is the medical necessity for the Inpatient stay. 
The health plan's determination of medical necessity is upheld in whole. 
No, the requested health service/treatment of Inpatient stay was not medically necessary for this patient. 

According to Up-to-date, 2019, "Features that suggest an additional complication, Complications of sickle cell disease (SCD) other than vaso-occlusive pain. In our experience, general features that suggest a greater likelihood of an additional complication include the following: Patient (or family) states that the pain is atypical for their vaso-occlusive pain, in severity or location, abnormal vital signs, major changes from the baseline complete blood count (CBC) or reticulocyte count, leukopenia or leukocytosis may indicate infection, including acute chest syndrome, worsening anemia may indicate bone marrow suppression (e.g., from infection), hepatic or splenic sequestration of blood, or increased hemolysis secondary to a delayed hemolytic transfusion reaction, increased hemoglobin concentration may indicate severe dehydration, decreased reticulocyte count from baseline, which usually would be elevated, may suggest bone marrow suppression. Markedly elevated reticulocyte count may suggest increased hemolysis or hepatic or splenic sequestration, pain associated with abdominal distention, which may indicate hepatic or splenic sequestration or acute cholecystitis, jaundice, which may indicate increased hemolysis or hepatobiliary disease, hematuria, which may indicate renal pathology, new laboratory abnormalities such as increasing creatinine, liver function tests, lactate dehydrogenase (LDH) or coagulation abnormalities, any findings attributable to acute chest syndrome, which is known to be increased in individuals with acute vaso-occlusive pain. Examples include hypoxia, cough, fever, or an infiltrate on chest radiography." 

The patient in this case was diagnosed with sickle-cell pain but did not have atypical pain, abnormal vital signs, major changes from his baseline CBC, abdominal distention, jaundice, hematuria, worsening liver or kidney function, or acute chest syndrome. The patient had uncontrolled pain but then was over sedated and was able to be converted back to his regular dose of home medications. 

Therefore, the inpatient stay was not medically necessary.