Diagnosis: Sickle Cell Pain Crisis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of sickle cell disease. He presented for care with back pain and chest pain that failed treatment with Tylenol and Motrin at home. He was found to have a blood pressure of 95/58, and his initial hemoglobin level was 8.1 grams per deciliter (g/dL) with a reticulocyte count of 11.44%. He was given intravenous (IV) fluids, Toradol, Ofirmev and morphine. He continued to have 5/10 level of back and chest pain so he was admitted for further treatment and monitoring. After admission he was given further IV fluids, and morphine was ordered around the clock every 4 hours with every 2 hour dosing for breakthrough pain. His back pain level decreased to 1-2/10 and he had no shortness of breath or chest pain. He was transitioned to oral pain medications and was discharged home later that day. The acute inpatient level of care from is under review for medical necessity.
The requested health service/treatment of inpatient stay was not medically necessary for this patient as the patient's care needs could have been safely provided at a lower level of care.
This patient was admitted for treatment of a sickle cell disease pain crisis. As per the Milliman Care Guidelines (MCG) 24th Edition: Sickle Cell Disease, admission is indicated for certain specific clinical concerns. It may be necessary for stroke, seizure, posterior reversible encephalopathy syndrome, or other central nervous system symptom or event, for acute chest syndrome, hypoxemia, need for emergent surgery, acute ischemia, acute renal failure, aplastic crisis, priapism or other vascular complication, traumatic hyphema, infection requiring inpatient treatment, altered mental status, inability to maintain hydration orally despite observation care treatment, or exchange transfusion. It may also be considered appropriate for treatment of pain insufficiently responsive to observation care treatment that requires treatment in the inpatient setting. While this patient had a need for frequent intravenous (IV) narcotic therapy, the patient had a 24-hour stay in the hospital that could have been safely met at a lower level of care. There were no complications related to his pain crisis, no documentation of acute chest pain, or other secondary issue. The care provided to this patient is consistent with the National Heart Lung Blood Institute guidelines for the management of sickle cell disease.
Therefore, based on the clinical information provided for review and the current standards of care, and peer-reviewed literature, this request for acute inpatient stay is not medically necessary at this time.