Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient is an adult male with Sickle Cell Disease. The patient presented to the hospital with an uncomplicated pain crisis. He left against medical advice (AMA) the following day. 

Per presentation assessment note, "Unlikely acute chest syndrome, aplastic crisis, splenic sequestration or other severe pathology as patient without any fever, chest pain (CP), shortness of breath (SOB), recent sickness or illness, splenomegaly or signs of infection on history and physical (H&P) or any other red-flag symptom." 

Laboratory results on presentation: White Blood Cells (WBC) 14.2 10x3/uL [Ref Range: 4.1 - 10.1], Red Blood Cells (RBC) 2.36 10x6/uL [Ref Range: 4.33 - 5.43], Hemoglobin: 7.8 g/dL [Ref Range: 12.9- 16.7], Hematocrit: 22.3 percent [Ref Range: 40 - 47], Mean Corpuscular Volume (MCV) 94.7 fL [Ref Range: 80.8 - 94.1], Mean Corpuscular Hemoglobin (MCH) 33.1 pg [Ref Range: 27.1 - 31.2], Mean Corpuscular Hemoglobin Concentration (MCHC) 34.9g/dL [Ref Range: 31.0 - 34.4]. 

In this case, there is documentation to support uncomplicated hemoglobin sickle cell crisis. Uncomplicated hemoglobin sickle cell crisis does not require acute level of care. This can be managed in alternative level of care such as observation. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. 

Per Simon E. et al. (2016), "SCD patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition." 

Per Cline, D. M., Silva, S., Freiermuth, C. E., Thornton, V., & Tanabe, P. (2018), "Use of alternative venues to manage uncomplicated vaso-occlusive crisis (VOC), such as a day hospital (DH) or ED observation unit, for patients with sickle cell anemia, may significantly reduce admission rates, which may subsequently reduce 30-day readmission rates... Over 30 months 427 patients (297 at Site 1 and 130 at Site 2) initiated 4,740 institutional visits, totaling 6,627 different acute care encounters, including combinations of encounters. The range of encounters varied from a low of 0 (203 of 500 patients [40.6%] at Site 1; 65 of 195 patients [33.3%] at Site 2), and a high of 152 (5/month) acute care encounters for one patient at Site 2. Patients at Site 2 were more likely to be admitted to the hospital during the study period (88.4% vs. 74.4%, p=0.0011) and have an ED visit (96.9% vs. 85.5%, p=0.0002). DH was used more frequently at Site 1 (1.207 encounters for 297 patients at Site 1, vs. 199 encounters for 130 patients at Site 2), and ED observation was used at Site 1 only. Thirty-five percent of patients visited hospitals outside their home academic center."  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.