Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic disease
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay as not medically necessary. 
The denial is upheld in whole. 

This case involves a patient with a history of sickle cell disease, who presented to the hospital with joint aches, which started the day before the presentation, with gradual worsening. The pain was reported at 8 out of 10 on the pain scale, similar to previous sickle cell crisis pains. The pain was unrelieved with Advil. On arrival, the patient was found to have a hemoglobin of 6.6, which is lower than the baseline hemoglobin of 7-8 g/dL. No prior history of exchange transfusions, but has had one simple blood transfusion one year before this presentation. The patient denied chest pain shortness of breath fevers or chills, nausea, vomiting, or abdominal pain. He denied hematuria or dysuria.
The laboratory studies showed a normal white blood cell count, with a mentioned hemoglobin of 6.6, mean corpuscular volume (MCV) of 71.6, and platelets of 330. Electrolytes, renal function, and liver function panel were reasonably unremarkable except for an elevated aspartate aminotransferase (AST) of 67. The lactate dehydrogenase (LDH) and reticulocyte count are reported as a baseline.
A chest x-ray showed no evidence of acute chest pathology. The patient was admitted to the hospital with a principal diagnosis of a vaso-occlusive crisis. Hematology consultation was requested, the patient was started on treatment for pain with intravenous (IV) Dilaudid every 4 hours, and was started on folic acid. Also, IV fluids were provided at 125 mL/h. Hematology consultant evaluated the patient and noted that the patient is chronically on folic acid but not on Hydrea. They requested a blood transfusion of 1 unit of packed red blood cells, and hemoglobin electrophoresis plus ferritin level before transfusion. They agreed with the rest of the treatment. The following day  the patient received 1 unit of packed red blood cells, with posttransfusion hemoglobin of 7.3. Shortly after that, the patient requested to leave the hospital to catch a plane and was discharged.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.
The patient presents to the hospital with a report of joint pain, consistent with previous presentations of sickle cell crisis. The patient has no evidence of stroke nor seizure. There is no evidence of acute chest syndrome, as the chest x-ray was clear. The patient complained of no chest pain, had no hypoxia, no tachypnea, or abnormal breath sounds documented on physical exam. There was no evidence of cholecystitis or splenic sequestration. Renal function is normal; there is no report of priapism. The patient's renal function is unaffected. There is no alteration of mental status, as clearly documented in the history and physical and the discharge note. The patient's pain was under control within 24 hours, as evidenced by own admission, that the patient is ready to leave the hospital. The patient received a simple transfusion, and not an exchange transfusion, which rapidly improved the hemoglobin to greater than 7.