Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Sickle Cell Crisis.
Treatment:  Inpatient hospitalization.

The insurer denied inpatient hospitalization.  The denial was overturned.   

The patient has a history of sickle cell anemia, venous thromboembolism (VTE), pulmonary embolism (PE), multiple transient ischemic attacks (TIA), and cerebrovascular accident (CVA).  The patient presented to the Emergency Department (ED) with complaints of right leg weakness and blurry vision.  The patient's vital signs were unremarkable.  The patient's hemoglobin was stable at 8.3, which was her baseline.  The patient had a negative computed tomography (CT) of the head in the ED.  The patient was admitted to the hospital for possible transient ischemic attack/cerebrovascular accident (TIA/CVA).  The patient had a magnetic resonance imaging (MRI) of the brain that was negative.  Hematology consulted sickle cell vaso-occlusive crisis, and the patient was treated with intravenous fluids, hydroxyurea (Hydrea), and folic acid, and was discharged.

As per Mangla et al., pharmacotherapy of sickle cell disease usually revolves around preventing its complications.  Hydroxyurea is an antimetabolite known to increase the fetal hemoglobin levels in the circulation of red blood cells (RBCs); fetal hemoglobin keeps hemoglobin in soluble form and prevents polymerization of the sickle cell hemoglobin, thus preventing most complications of sickle cell disease.  Opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, antiemetics, tricyclic antidepressants, and antibiotics are all used to cure or ameliorate the complications of the disease.  Folic acid supplementation prevents macrocytic anemia. 

As per Sedrak, the management of sickle cell complications is tailored to the type of complication.  Vaso-occlusive crisis (VOC) management consists of rapid pain assessment, early initiation of analgesic therapy and maintaining analgesia and hydration until there is symptom relief.  For most other complications, like acute chest syndrome, splenic sequestration and strokes, meticulous supportive care (oxygen, judicious fluid administration) and transfusion therapy are needed.  Among patients who have frequent and severe complications, hydroxyurea has been shown to offer significant benefit.  Hematopoietic stem cell transplantation (bone marrow transplantation) shows great promise as a cure for sickle cell disease. 

For a patient presenting with history of sickle cell anemia and history of cerebrovascular accident (CVA) with new complaints of leg weakness and blurry vision, hospital admission for evaluation of CVA is considered medically necessary and appropriate.  In this case, this patient's clinical presentation was concerning for recurrent CVA, which should be managed in an acute care setting.  The literature review support the acute level hospitalization for this patient with sickle cell anemia, who presented with new neurological findings concerning for CVA.

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

The carrier's denial of coverage for inpatient hospitalization months is overturned.  The medical necessity is substantiated.