Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Anemia.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a past medical history significant for chronic kidney disease, hypertension, and sickle cell anemia, who was brought to the emergency department with generalized body aches and a headache. It was reported that 2 days before his presentation he was seen and diagnosed with anemia. At that time his hemoglobin was 5.3, and a blood transfusion was arranged, but the patient decided to leave the hospital against medical advice.

His review of systems was positive for abdominal pain, dizziness, and light headaches. When seen by the admitting physician, his temperature was 99.1 degrees Fahrenheit (F), blood pressure was 148/88, pulse rate 77 beats per minute (bpm), respiratory rate 16 breaths/minute, and oxygen saturation 98% on room air.

The head, eyes, ears, nose, throat (HEENT) exam was within normal limits except for the presence of scleral icterus. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. There was abdominal tenderness to palpation. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that white blood cell count was 15.2, hemoglobin 4.7, hematocrit 12.8, and platelets 257. The sodium was 140, potassium 4.6, chloride 114, bicarbonate 16, blood urea nitrogen (BUN) 37.6, creatinine 3.87. The alanine aminotransferase (ALT) was 18, aspartate aminotransferase (AST) 58, alkaline phosphatase 118. The total bilirubin was 4.7.

A chest x-ray demonstrated no dense consolidation or pleural effusion. There was cardiomegaly and questionable mild pulmonary venous congestion. Computed tomography (CT) scanning of the head without contrast revealed cerebellar atrophy with areas of encephalomalacia in both cerebellar hemispheres. There was a 3-millimeter (mm) area of encephalomalacia in the head of the left caudate nucleus. An electrocardiogram (EKG) revealed normal sinus rhythm with left ventricular hypertrophy with repolarization abnormality.

The patient was admitted to the hospital with sickle cell disease and anemia. Two units of packed red blood cells were transfused. The patient received treatment with intravenous fluids, folic acid, and Dilaudid. For the treatment of hypertension, he was continued on Nifedipine. It was noted that the patient has stage IV chronic kidney disease. As a result of the transfusion, the patient's hemoglobin went up to 7.3.
The patient decided to leave the hospital against medical advice again the next day after the day of admission. According to the attending physician, the patient appeared comfortable and denied chest pain. The attending physician emphasized the importance of outpatient follow-up in the clinic after discharge.

At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

The patient presented to the hospital with sickle cell anemia; however, there was no evidence that the anemia was associated with any involvement of the central nervous system, since there was no evidence that the patient had a stroke, seizure, or posterior reversible encephalopathy syndrome, or any other central nervous system symptoms. There was no evidence that the patient had acute chest syndrome. The chest x-ray did not demonstrate new alveolar infiltrates.

It was clearly documented in the review of systems that the patient had no chest pain, there was no evidence of hypoxemia, tachypnea, tachycardia, abnormal breath sounds on the exam, or cough with sputum production. There was no evidence of hypoxemia. The patient did not need any emergency surgery. There was no evidence of acute ischemia.

There was no documentation of acute kidney injury. Instead, it was documented that the patient had chronic kidney disease. There was no documentation that the patient had any infection requiring inpatient treatment. The patient was able to tolerate his meals.

There was no evidence that the patient had any underlying conditions requiring hospitalization.

Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.