Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Disease. 
Treatment: Inpatient Hospital Admission. 

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

The patient has a past medical history significant for sickle cell disease, multiple pulmonary embolisms, chronic anticoagulation with Lovenox, and previous history of vaso-occlusive crisis who presented to the hospital with complaints of bilateral lower extremity pain. 

The patient stated that she was seen in the emergency department one week before her presentation. The patient stated that the pain was not adequately controlled despite taking 4 milligrams (mg) of oral Dilaudid every four hours. At the same time, the patient denied a fever, chills, chest pain, shortness of breath, lightheadedness, numbness, or tingling. There were no complaints of headaches or vision changes.
Upon initial evaluation in the emergency department, the patient was afebrile. The blood pressure was 138/74, heart rate 115 beats per minute (bpm), respiratory rate 17 breaths/minute, and oxygen saturation 98% on room air. 
The review of systems was positive for prolonged menstrual bleeding that lasted for 13 days, arthralgias, and back pain. The rest of the review of systems was negative. When seen by the admitting physician, the patient was not in distress. 
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. There was muscle tenderness present, but the patient had a normal range of motion in the extremities. The rest of the physical exam was unremarkable. 
Laboratory evaluation revealed that the white blood cell count was 10.5, hemoglobin 9.0, hematocrit 27.8, and platelets 428. The sodium was 143, potassium 4.9, chloride 112, blood urea nitrogen (BUN) 9.0, creatinine 0.64, glucose 100. Thyroid stimulating hormone (TSH), free T4, and folate were normal. The reticulocyte count was 7.8. Alanine aminotransferase (ALT) was 83, aspartate aminotransferase (AST) was 84. Troponin was normal. A chest x-ray showed no evidence of acute cardiopulmonary process. 

The patient was admitted to the hospital with a diagnosis of sickle cell vaso-occlusive crisis. The patient received treatment with intravenous fluids, intravenous pain medications, oral pain medications, Benadryl, folic acid supplements, and hydroxyurea.
In the hospital, the patient was seen by a hematologist who indicated that the patient's hemoglobin was at the baseline. The hematologist recommended monitoring of oxygen saturation, optimization of pain management, daily monitoring of the complete blood count (CBC), complete metabolic profile, reticulocyte count, lactate dehydrogenase (LDH), and direct bilirubin. 

During the hospital stay, the patient remained afebrile and hemodynamically stable. Her symptoms improved, and she was transitioned to outpatient care. 

At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was medically necessary in this clinical case, since the pain was not adequately controlled with oral pain medications that were administered even before this admission. This necessitated the administration of intravenous pain medications to get the pain under adequate control. 
The patient presented to the hospital with complaints of severe pain in the lower extremities that was attributed to a vaso-occlusive crisis due to sickle cell disease. It was noted that at home the patient already received treatment with a relatively high dose of oral Dilaudid, without significant alleviation of the symptoms. 

Therefore, the patient was admitted to the hospital and received treatment with parenteral pain medications including intravenous Dilaudid to get the pain under control. The frequent administration of intravenous Dilaudid required admission at the acute inpatient level of care. 

This coincides with MCG Health Inpatient & Surgical Care 24th Edition criteria for Sickle Cell Disease. Based on the criteria, admission at the acute inpatient level of care is recommended if the pain is insufficiently responsive to observation care treatment and requires administration of parenteral opioids in inpatient settings. This criterion adequately described the circumstances in this clinical case. It is a common clinical practice to admit a patient at the acute inpatient level of care if they require frequent administration of parenteral opioids, in the setting when treatment with oral pain medications did not lead to adequate pain control.