Diagnosis: Blood Disorder (Sickle cell disease)
Treatment: Inpatient Hospital

Summary: This patient with known sickle cell (SC) disease (not sickle trait, but hemoglobin sickle cell (Hgb SC) disease), was transferred from the Psychiatric ward with complaints of abdominal pain that was 9/10 in intensity and was similar to a prior SC crises. The medical record indicated that the patient had an enlarged spleen on ultrasound, elevated reticulocyte count and an elevated lactate dehydrogenase (LDH). In addition, the platelet count was 175 (normal for that lab 180). All of these labs are consistent with SC hemolysis, and the combination of splenic enlargement and thrombocytopenia are consistent with SC crisis and splenic sequestration (which at this age is more common in patients with Hgb SC disease). The admission note stated that the patient was not taking adequate oral hydration, and as such, prolonged intravenous (IV) hydration was indicated both for the ongoing sickling hemolysis and possible splenic sequestration.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was reversed.

The inpatient Psychiatric ward is not suited to manage such a medical issue as SC pain and crisis. Given the lab findings and clinical complaints concerning for SC crisis, hemolysis and possible splenic sequestration in this patient with psychiatric concerns, inpatient management was appropriate. It is commonly understood and widely published that in children and young adults with SC disease the description of pain is often the only sign of SC crisis. As such, for a patient in whom ambulatory analgesia has not been sufficient, hospitalization for management of pain is standard of care. Hospitalization for management of pain with IV analgesia (ketorolac), IV hydration and to monitor for escalation of care as needed was within standard of care. The patient had significant pain consistent with SC crisis, and labs and imaging findings were concerning for splenic sequestration. Hospitalization for management of pain with IV analgesia and to monitor for escalation of care as needed was within standard of care. Her length of stay was justified by the interventions she received and the need to ensure her pain would be adequately controlled upon discharge. The medical necessity is substantiated.