Diagnosis: Sickle cell (SS) disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

In the documentation given for review it shows the patient has sickle cell (SS) disease. He presented to the emergency room (ER) with myalgias and sickle cell pain crisis. He was given intravenous (IV) fluid, pain medications, and oxygen. He refused testing and treatment and left against medical advice (AMA). He was afebrile.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. As noted above, the patient presented to the ER with myalgias and sickle cell pain crisis. He was given IV fluids, pain medications, and oxygen. He was afebrile. The patient refused testing and treatment and left AMA. The plan's denial was appropriate, in this case.

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"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 health plan acted reasonably with sound medical judgment in the best interest of the patient.

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