Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Hand Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient is a male teen with medical history significant for sickle cell disease, including splenectomy and multiple admissions for vaso-occlusive crisis, aplastic crisis secondary to Parvovirus infection, need for transfusion, and acute chest syndrome (two PICU [pediatric intensive care unit] admissions). He presented to Hematology Clinic with one-day history of sore throat and fatigue. In clinic, he was ill-appearing, with oropharyngeal exudate, and rapid testing positive for Strep. He was given hydration and a prescription for amoxicillin and sent home but was unable to take the medication due to pain. He presented to the ED (emergency department) later that day, noted to have fever, and was treated with Tylenol and IV (intravenous) penicillin G. He subsequently felt better, when he developed intermittent cramping pain in both hands atypical for his usual pain crisis pain. The pain was rated 8/10. He had no fevers at home, and he did not report any hand or joint swelling.

The patient returned to the ED (emergency department), where vital signs included temperature 101.1, heart rate 118, respiratory rate 20, and blood pressure 93/56. Examination was significant for non-toxic appearance, bilateral tonsillar enlargement without exudates, tachycardia, moist mucous membranes, and non-focal neurologic exam. Differential included sickle cell crisis versus systemic infection. Laboratory evaluation was significant for leukocytosis (WBC [white blood count] 20.5K [thousand]), anemia (hemoglobin 6.0, lower than baseline), mild thrombocytosis (platelets 482K [thousand]), reticulocytosis (9.3%), normal venous lactate (1.8), hyponatremia (sodium 129), and hyperbilirubinemia (4.3).

The patient was treated with a normal saline bolus, a dose of ibuprofen, and ceftriaxone prior to admission. Admission orders included IV (intravenous) fluids, daily ceftriaxone, regular diet, famotidine for stomach protection, morphine every four hours as needed for pain, anti-pyretics, home medications (folic acid, hydroxyurea), follow-up cultures and Covid testing, and repeat labs. Repeat hemoglobin had fallen even further to 5.3, so he was transfused. He remained on ceftriaxone. His pain improved, managed with Tylenol and Motrin. Cultures and Covid testing were negative. He was deemed stable for discharge to follow-up with his primary care practitioner and in Hematology Clinic.

Yes, the Inpatient admission was 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 requiring splenectomy (increasing risk of infection and sepsis), dactylitis, stroke, generalized altered immune function with increased risk of bacterial sepsis, pulmonary hypertension, and renal disease.

Evaluation and management of vaso-occlusive crisis are particularly problematic because patient presentation and reported severity of pain are oftentimes inconsistent or contradictory; reported severity should not be down-played or ignored. In addition, many patients have undergone splenectomy due to sequestration and thereafter remain at risk for sepsis particularly from encapsulated organisms such as Streptococcus. Any fever should be taken very seriously as it may be the only warning of impending sepsis and shock.

The young man presented to the ED (emergency department) with somewhat atypical yet severe pain in his hands and had just received treatment for Strep pharyngitis, a single IV (intravenous) dose of penicillin. He was febrile, with leukocytosis and worsening anemia on laboratory evaluation. There was reasonable concern for sepsis as well as some form of pain crisis. He was admitted for parenteral antibiotics and parenteral pain management. The care that he received was most consistent with acute inpatient management. He could not have been safely or appropriately managed at a lower level of care.