Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adolescent male with the diagnosis of sickle cell anemia with review for inpatient hospital admission.

The patient presented to the emergency department for evaluation of a pre-syncopal episode at home. The mother endorsed the patient started feeling dizzy and lightheaded causing him to sustain a ground-level fall. On exam, the patient was noted to be pale and had abdominal tenderness. 

The proposed inpatient hospital admission was not medically necessary.

The patient presented to the emergency department for evaluation of a pre-syncopal episode at home. On exam, the patient was noted to be pale and had abdominal tenderness. The emergency department physician ordered labs and imaging. Labs demonstrated a white blood cell count of 17.4, hemoglobin of 7.7 and platelet count of 678,000. D-dimer was elevated. The patient was treated with intravenous fluids, intravenous antibiotics and transfused one unit of packed red blood cells.

Review of the medical record demonstrates that the patient has a baseline hemoglobin of nine to ten, and underlying diagnosis of hemoglobin SS. The most recent complete blood count (CBC) prior to this admission was last year and showed a hemoglobin of 8.2. The patient is on hydroxyurea and had a prior admission for sickle cell complications several years ago. He had one history of admission for acute chest syndrome several years ago. There is no history of sequestration. No history of stroke. Evaluation last year was a benign cardiac exam with left ventricular hypertrophy on electrocardiogram. His left ventricular dilation was improved and was only mild. 

The history of present illness demonstrates the patient has a baseline hemoglobin of nine to ten and was referred from hematology clinic due to paleness. After taking a shower that morning, while he was dressing, he felt dizzy and fainted to the floor. There was no head trauma. Review of systems showed that the patient had abdominal pain and vomiting as well as dizziness and lightheadedness. On exam, the patient looked comfortable with no acute distress. He was pale in the feet and hands. He had an audible murmur. The patient was transfused one unit of packed red blood cells and given a dose of ceftriaxone. His hemoglobin was 7.7, white blood cell was 17 which is not abnormal for this patient with hemoglobin SS and would not be considered abnormal. He had mild thrombocytosis which is not of significant concern. Blood gas did not show any significant acidosis. The patient had a normal lipase. He had a normal amylase. The patient was afebrile. His lactate dehydrogenase (LDH) was elevated at 1345 which again is not abnormal in the setting of an underlying hemolytic anemia. Electrocardiogram (EKG) and chest x-ray did not show any abnormalities.

The patient was discharged the following day. In this case the proposed treatment at inpatient level of care would not be considered medically necessary or consistent with standard practice. The patient presented with a syncopal episode. His hemoglobin was slightly below baseline for him in the setting of a known chronic hemolytic anemia. As such, it is unlikely that anemia would have been the cause of his syncopal episode. The patient looked well and was hemodynamically stable on initial assessment. He did not have any laboratories that were significantly abnormal or that needed closer monitoring. The patient was transfused a unit of packed red blood cells and was discharged within an observation period of time. As such, observation level of care is the most appropriate level of care in this setting. The patient did not have any sickle cell complications that warranted inpatient level of care such as acute chest syndrome, stroke, blood infection, splenic sequestration or any other inpatient level of care sickle cell crisis.