Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Genetic Diseases. 
Treatment:  Inpatient Hospital.

The insurer denied inpatient hospital admission for medical necessity.  The denial was upheld. 

This patient is a female with a past medical history of sickle cell disease and ulcerative colitis.  She presented to the emergency department with back, chest, and abdominal pain.  On presentation, she was afebrile with a blood pressure at 118/73, heart rate was 88, respiratory rate was 16, and oxygen saturation was 92-100% on room air.  Her exam otherwise noted her to be in no acute distress without any other acute exam abnormalities.

Her labs resulted with a white blood cell count (WBC) at 3.96, Hemoglobin (HGB) was 8.9, platelets were 152, sodium was 138, potassium was 4, blood urea nitrogen (BUN) was 15, creatinine was 0.6, total bilirubin was 2.7, aspartate aminotransferase (AST) was 30, alanine aminotransferase (ALT) was 18, alkaline phosphatase was 54, and lipase was 35.  A chest x-ray showed no acute process.  Her electrocardiogram showed no clear acute ischemia or arrhythmia.

In the emergency department, she was given 3 doses of Dilaudid intravenous (IV) in addition to Tylenol, Zofran IV, and IV fluids.  The patient was brought into the hospital with concerns for sickle cell anemia and pain crisis in addition to elevated liver function tests stable from prior, and abdominal pain not consistent with sickle cell crisis, and ulcerative colitis flare.  The plan was for IV fluids, IV and oral pain control with opiates, hydroxyurea, continuation of mesalamine, trending liver function tests, hematology consult, and following labs.

The patient remained hemodynamically stable.  Her HGB was stable in the 7-8 range.  She was continued on IV fluids.  She was on oral Dilaudid that was titrated up to 6 milligrams (mg) doses every 4 hours by with good effect and without a need for IV opiates for pain control.  She was otherwise continued on her home medications.  She was seen by hematology with assessment that she could be discharged on oral opioid therapy with long acting and short acting opiates. She was ultimately discharged.  At issue is the inpatient level of care for medical necessity.

The health plan's determination of medical necessity is upheld in whole.  The requested health service/treatment of inpatient stay was not medically necessary for this patient.
 
This is a patient, who presented with pain concerning for sickle cell crisis.  There was no concern for acute chest syndrome, an acute neurologic event such as stroke or seizure, acute colitis or other infection leading to the sickle cell crisis, aplastic crisis, or other acute destabilized medical condition requiring an inpatient level of care.  It is noted that after emergency room therapy, the patient was stabilized quickly on a regimen of oral opiates with IV opiates not required.  There was no need for further imaging or work-up of sickle cell complications after presentation.

The patient was deemed stable for discharge and outpatient follow up, when seen by hematology, on long-acting oral opiates with short-acting opiates for breakthrough.  The patient had a quick stabilization of pain on oral opiates; there was no suspicion for sickle cell complications aside from pain crisis, and there was no further imaging or work-up done after presentation.  The primary plan was for pain control.

Therefore, the inpatient level of care was not medically necessary.