Diagnosis: Sickle cell disease
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a teenage male with review for inpatient hospital admission. The patient has a history of sickle cell disease, polycystic kidney disease, single kidney, and asthma. He presented to the emergency department with complaints of left shoulder and right hip pain. He was hemodynamically stable and afebrile. Laboratory studies demonstrated a white blood cell count of 12.5, hemoglobin 6.8 and platelet count 446 thousand (K). The patient had an appropriate reticulocytosis. The patient was hyponatremic with a sodium 130 and he had a bilirubin of 4. X-ray of the hip demonstrated normal findings. The patient was admitted to the hospital for intravenous fluids and pain medication. The patient was transfused 1 unit of packed red blood cells. Orthopedics was consulted and recommended management for sickle cell vaso-occlusive crisis. The patient was discharged on day #3.

The proposed inpatient hospital admission was not medically necessary.

In this case, acute inpatient level care would not be considered medically necessary for this patient. The patient was admitted to the hospital with hip and shoulder pain. The patient was afebrile. The patient did not have any significant sickle cell complications such as acute chest syndrome, stroke, aplastic crisis, duration or intractable pain beyond observation level of care, splenic sequestration, fever or bacteremia. The patient had a normal pulse oximetry and did not require any oxygen supplementation. The patient was given 1 transfusion. As such, in this case acute inpatient level care would not be considered medically necessary. Ambulatory/observation level care is more appropriate in the setting given the patient's symptoms resolved within time and there were no inpatient level of care needs as described above.