Diagnosis: Sickle Cell Disease
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient in this case is a male who has a history of sickle cell anemia. He presented to the emergency department with complaints of generalized body aches, most prominent in his lower back and legs. The pain had been present for two weeks. He said that these symptoms were typical of sickle cell crisis. He had no other symptoms and noted that he had been treated in the outpatient setting over the past two weeks but the pain was worsening.

The patient's vital signs were unremarkable except for mild elevation in heart rate to 101. Physical exam was without significant abnormal findings. Labs were notable for hemoglobin of 6.3 grams per deciliter (g/dl). This was noted to be stable for him. He was treated with two doses of intravenous (IV) Dilaudid and continued to complain of pain. He was admitted. He was not transfused. Chest x-ray revealed a questionable ground class opacity. He was treated with intravenous (IV) fluids and Dilaudid and left against medical advice.

No, the proposed inpatient admission was not medically necessary.
This patient had been having pain for two weeks and did not have any hemodynamic instability, respiratory compromise, acute kidney injury or active infection requiring intravenous (IV) antibiotics. He also did not have severe pain requiring frequent use of intravenous pain medication. He had persistent pain over a period of two weeks and was well enough to leave against medical advice soon after admission. He did not require acute care inpatient admission based on these considerations.