Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Crisis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient a diagnosis of sickle cell crisis. The patient was admitted for control of the acute vaso-occlusive disease. The request is for inpatient admission which is under medical review.

The patient had dropped their hemoglobin, had tachycardia, and had a continued need for intravenous (IV) narcotics to control their pain. In addition, the patient was seen the day before in the emergency room (ER) and discharged. In this clinical setting, admission would be the prudent next step for pain control.

"The most common acute complication of sickle cell anemia (SCA) is Vaso-occlusive crisis (VOC). The treatment section below discusses the management of acute and chronic issues. Management of Acute Complications: Pain management is a critical part of SCA. It is challenging for clinicians to accurately assess patients' needs, especially if they meet them for the first time. Patients with SCA often suffer from the stigma of requiring high doses of opioids for pain control, which leads to them being labeled as 'opioid abusers,' 'manipulators,' or even' drug seekers.' Analgesic administration starts simultaneous with evaluating the cause, ideally within 30 minutes of triage and 60 minutes of registration. Pain should be reassessed every 15 to 30 minutes and readminister opioids if needed. The escalation of opioids is done in 25% increments. Patient-controlled analgesia (PCA) is preferred. If an "on-demand" setting is used in PCA, then continue long-acting analgesia. When pain control is achieved, "wean off" parenteral opioids before converting to oral medications. Calculate the inpatient analgesic requirement at discharge and adjust home doses of short and long-acting opioids accordingly. upportive measures should be instituted along with pain management: Incentive spirometry, Intravenous hydration, Supplemental oxygen is needed only if saturation drops below 95% on the room air" (Mangla, A., Ehsan, M., Agarwal, N., et al. 2022).

"The goal of acute pain management is to provide sufficient analgesia to return patients to their usual function, which may mean complete resolution of pain for some or return to baseline chronic pain for others. The goal of chronic pain management is to optimize individuals' function, which may not mean being pain free. When there is an identifiable cause of chronic pain, treatment of the underlying issue (e.g., joint replacement for avascular necrosis, leg ulcer treatment) is important. Opioids, oral for outpatient management and intravenous for inpatient management, are first line therapy for acute sickle cell disease (SCD) pain. In the acute care setting, analgesics should be initiated within 30-60 min of triage." (Brandow, A. M., & Liem, R. I. 2022).

"Patients with sickle cell disease (SCD) have vaso-occlusive crises (VOCs). Infusion centers (ICs) are alternatives to emergency department (ED) care and may improve patient outcomes. In adults with SCD having a VOC, treatment in an IC is associated with substantially better outcomes than treatment in an ED" (Lanzkron, S., et al. 2021).                                                         

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.