Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Sickle Cell Disease

Treatment inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a female with history of sickle cell anemia, acute chest syndrome, migraine headaches, pulmonary embolism (multiple episodes), bilateral hip avascular necrosis requiring a right hip replacement, stroke, and transient ischemic attacks. She presented to the Emergency Room (ER) in a sickle cell crisis with pain in her back, right hip and leg. She complained of palpitations. Her heart rate was noted as 138 beats per minute. An electrocardiogram (EKG) indicated sinus tachycardia. She received monthly infusions of crizanlizumab via a right chest port, her next infusion was due in a week. Bloodwork indicated an elevated D-Dimer and mild leukocytosis. A computed tomography angiography (CTA) showed no gross abnormalities; however, a few osteolytic and osteosclerotic lesions were noted as well as nodules and ground-glass opacities in both lungs. Intravenous (IV) fluids, IV pain medication and IV antihistamine were administered through her right chest port. She was admitted for further management of her sickle cell pain crises. Hematology/Oncology service concluded lesion findings were likely due to chronic sickle cell disease. A note says that she was feeling better and asking to be discharged on that day. She was ambulating in the ER. She was discharged with instructions to follow-up with Hematology/Oncology as an outpatient.

"Sickle cell disease (SCD) is a group of inherited red blood cell disorders affecting about 1 in 500 African American children and 1 in 36,000 Hispanic American children. SCD results in anemia and sickle cell crisis (SCC). The main clinical feature of sickle cell disease is the acute painful crisis, which often requires hospitalization. The term sickle cell crisis is used to describe several acute conditions such as the vaso-occlusive crisis (acute painful crisis), aplastic crisis, splenic sequestration crisis, hyperhemolytic crisis, hepatic crisis, dactylitis, and acute chest syndrome. Other acute complications include pneumonia, meningitis, sepsis and osteomyelitis, stroke, avascular necrosis, priapism, and venous thromboembolism... Rapid pain assessment and initiation of analgesia should be undertaken promptly. Depending on the degree and severity of pain, analgesic administration can be given intravenously (IV) or intranasally. For patients who are not in severe pain and can tolerate oral medications, oral analgesics can be used. Generally, the type, route, and dose of the analgesic should be individualized to the patient." (Borhade, M. B., & Kondamudi, N. P.) 

The severity of symptoms is not clear. A note says that she was feeling better and asking to be discharged on that day. She was ambulating in the ER. Bone changes were thought by Hematology to be chronic. Hydration and/or transfusion could have been done in the ER with an observation period in the ER and earlier discharge, and then outpatient management. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. She appears to have been feeling better and asking to go home on the initial visit but stayed in the ER under the rubric of admission and was discharged.       

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.