Diagnosis: Sickle cell crisis

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial was reversed.

This patient is a male child with a history of sickle cell disease, Type 1 diabetes mellitus-on insulin pump at home, asthma, and priapism, who presented to the Emergency Department (ED) with a complaint of lower back and right leg pain on and off for one month. He has been taking ibuprofen and Oxycodone but ran out of the medications that day. Per the ED provider note the patient reported that the pain worsened on the day he presented to the ED and he called his hematologist who recommended that he go to the ED. The patient denied shortness of breath, chest pain, fevers, cough, congestion, and abdominal pain. He reported that his last urine dipstick was in the 300's in the morning.

According to InterQual Criteria: "Patients with [vaso-occlusive crisis] VOC [who] present with severe pain. The diagnosis is based upon the history and physical examination. The laboratory tests are not useful to confirm the disorder. Analgesic administration should be individualized based on the patient's home regimen. Aggressive and timely pain management is key to rapid resolution of VOC. ...Additional supportive measures include hydration..." The patient clearly meets this description.

It is commonly understood and widely published (as noted in the references below) that in children and young adults with sickle cell disease the description of pain is often the only sign of sickle cell 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 intravenous (IV) analgesia, IV hydration and to monitor for escalation of care as needed was within standard of care.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital stay was considered medically necessary for this patient.

Based on the above, medical necessity for the inpatient hospital stay is substantiated. The insurer's denial is reversed.