Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell anemia
Treatment: Inpatient hospital admission
The insurer denied: Inpatient hospital admission
The denial is upheld.

This patient is a school age female child with a medical history significant for sickle cell anemia and vaso-occlusive crisis who presented to the emergency department with persistent pain in her right leg and abdomen. She had been seen the day before with pain and labs consistent with vaso-occlusive crisis. She had no fevers, cough, chest pain, or trauma. She was treated with ibuprofen and acetaminophen without improvement. Vital signs included temperature 37.3, heart rate 113, respiratory rate 26, and blood pressure 108/62. Examination was significant for no respiratory distress, good aeration, no murmur/gallop/rub, abdomen with voluntary guarding, full range of motion of bilateral hips, diffuse tenderness to palpation of right leg without swelling or erythema, no rash, and a non-focal neurologic exam. Rapid viral screen was negative. Laboratory studies were remarkable for white blood cell count 19.6 thousand, hemoglobin 10.3, platelets 379 thousand, reticulocytes 236, total bilirubin 1.3, alanine aminotransferase (ALT) 76, and aspartate transaminase (AST) 109. She was treated with intravenous fluids and Toradol, after which she tolerated full passive range of motion of her right knee and hip. The case was discussed with Hematology, and she was subsequently admitted for further management of pain. 
Admission orders included Toradol and Tylenol round-the-clock, morphine as needed every four hours, hot packs and lido packs as needed, incentive spirometry and ambulation, intravenous fluids at 2/3 maintenance, continued home hydroxyurea and folic acid, continued home penicillin, Pepcid while on non-steroidal anti-inflammatory drugs (NSAIDs), and bowel regimen with Miralax/Senna/Colace. The patient initially required some morphine doses along with the routine Toradol and Tylenol. Repeat laboratory studies indicated stable hemoglobin and 
normalized white blood cell count. The patient's pain significantly improved. She was successfully transitioned to oral pain medications and deemed stable for discharge on day #3.

The acute inpatient admission was not medically necessary.

Sickle cell anemia is a common genetic disease in which hemoglobin in red blood cells is replaced by an abnormal form, hemoglobin S. This causes red blood cells to form sickling shapes that block small blood vessels. In addition, these red blood cells do not survive as long, causing anemia. As a result, multiple complications can occur, including chronic anemia, acute chest syndrome, vaso-occlusive crisis, splenic sequestration, dactylitis, stroke, altered immune function with increased risk of bacterial sepsis, pulmonary hypertension, and renal disease. Pain management is a critical feature of patient care and frequently requires parenteral therapy to achieve improvement and relief. This young child with a history of vaso-occlusive crisis had worsening pain in her abdomen and 
right leg refractory to pain management at home. While it was reasonable and medically necessary to monitor the patient in the hospital for administration of parenteral pain medications, she was overall hemodynamically stable with no evidence of acute chest syndrome and no evidence of sepsis or impending sepsis. She did not require acute inpatient admission and could have been safely managed at a lower level of care.