Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Sickle Cell Disease, Pain Crisis 
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.   
This is a patient with a medical history of sickle cell disease, iron overload secondary to frequent transfusions, asthma, migraines, multiple strokes, scoliosis with spinal correction surgery, and a remote history of acute chest syndrome.  She had been treated the month prior to presentation for acute pain crisis.  She presented to the emergency department with lower back pain, ankle pain and swelling in the mid-shin.  The patient's pain was treated with opioids; improvement was noted.  The patient left against medical advice.  There was no evidence that the patient was not stable, had chest syndrome or had a change in vital signs.  Hydration and pain medications could be given in an observation level of care.  In addition to general stability and no evidence of decompensation, her pain seemed to have come under control fairly quickly, and she left against medical advice (AMA).  Pain management was with intramuscular (IM) Dilaudid, which could be done at a lower acuity level.
"The main clinical feature of sickle cell disease is the ''acute painful crisis,'' which often requires hospitalization.  The term "sickle cell crisis" is used to describe several acute conditions such as the vaso-occlusive crisis (acute painful crisis), aplastic crisis, splenic sequestration crisis, hyperhemolytic crisis, hepatic crisis, dactylitis, and acute chest syndrome.  Other acute complications include pneumonia, meningitis, sepsis and osteomyelitis, stroke, avascular necrosis, priapism, and venous thromboembolism. Rapid pain assessment and initiation of analgesia should be undertaken promptly.  Depending on the degree and severity of pain, an analgesic administration can be given intravenously (IV) or intranasally.  For patients who are not in severe pain and can tolerate oral medications, oral analgesics can be used.  Generally, the type, route, and dose of the analgesic should be individualized to the patient.  Most guidelines recommend early initiation of parenteral opioid analgesics, usually with morphine at 0.1 mg/kg IV or subcutaneously (SC) every 20 minutes and maintaining this analgesia with morphine at doses of 0.05 to 0.1 mg/ kg every 2 to 4 hours (SC/IV or oral [PO]).  Those with persistent pain benefit from a patient controlled analgesia [PCA] pump.  Close monitoring of vital signs including oxygen saturation should be maintained with frequent reassessments of pain severity or resolution.  If the pain is controlled, the patient may be ready for discharge with a home care plan and oral analgesia.  If the pain is uncontrolled despite the above treatment plan, consider hospitalization and the use of stronger forms of analgesia or higher doses titrated to the patient's needs." (Borhade et al. 2019).

"It is likely that many of the frequent attenders in emergency departments (EDs) are suffering from chronic pain as well as an acute painful vaso-occlusive crisis.  The majority of adults and older children will have severe pain (pain score >7 on a 10-point scale) in the early stages of a hospitalized episode of pain.  The most rapid reduction in pain score is during the early stages, followed by a plateau, and many patients still have a pain score >7 at time of discharge.  Attempts to control pain completely are unrealistic and result in excessive analgesic dosing.  Pain management aimed at reducing pain to a moderate level (4-6) is more realistic, and patients should be counseled that they may not be completely pain-free when discharged from the hospital." (Telfer et al. 2017).                                                         

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.