Diagnosis: Sickle Cell Crisis.

Treatment: Inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a has a past medical history (PMH) of sickle cell disease, avascular necrosis, and acute chest syndrome. The patient presented with sickle cell anemia and was admitted.

According to the clinical documentation provided for review, the patient has the past medical history (PMH) of sickle cell disease, avascular necrosis, and acute chest syndrome. The patient had an uncomplicated sickle cell pain crisis. The patient had a history of avascular necrosis (AVN). The patient's computerized tomography (CT) scan of the chest did not demonstrate infiltrates. The patient was given intravenous (IV) fluid and pain medication. The patient was discharged the following day.

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

The patient with an uncomplicated acute sickle cell pain crisis, does not need acute level hospitalization on presentation. The majority of these patients will improve with standard conservative measures within 12 to 24 hours. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. Therefore, the request for the inpatient hospital admission is not considered medically necessary for this patient.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018).

The insurer's denial of coverage for the inpatient hospital admission is upheld Medical Necessity is not substantiated.