Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell disease (SCD).
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

The patient presents with a medical history of sickle cell anemia, deep vein thrombosis (DVT), pulmonary embolism (PE) on chronic anticoagulation therapy, bacteremia, compensated congestive heart failure (CHF) and ischemic bowel. 

The admission note indicates that the patient presented with pain that was a 10 out of 10. There were erythematous patches on his left leg. There was history of chronic anticoagulation, bacteremia, compensated congestive heart failure (CHF) and ischemic bowel. The patient was admitted with sickle cell crisis and treated with intravenous (IV) Dilaudid. The patient also had right upper quadrant (RUQ) pain that gradually subsided. The patient's pain was decreasing, and Dilaudid began to be decreased. The progress note states that the patient was pain free and asked to be discharged. 

The patient was in pain until the day of discharge. The notes, unfortunately, carry over the assessments from day to day and do not rate pain daily. However, for example, the patient's pain increased, and he asked for more Dilaudid. As such, a discharge was not yet appropriate. The note says that the patient is still in pain but agrees to decrease Dilaudid. This request and all days before the day of discharge are appropriate.

"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." (Borhade, et al., 2019).

"The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned..." (Telfer, et al., 2017).

Based on the review, the inpatient admission was considered medically necessary for this patient 

The health plan did not act reasonably, with sound medical judgement or in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission reversed. Medical necessity is substantiated.