Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adolescent female with a past medical history of type II diabetes, not compliant with metformin 750 mg (milligrams) BID (twice daily). The patient has hypertension with eccentric LVH (left ventricular hypertrophy).

The patient was admitted for diabetes education glucose monitoring. She was initially diagnosed with type II diabetes and was prescribed metformin BID 750 mg. The medication was self-discontinued a few months later, and follow-up did not occur due to COVID (coronavirus).

The patient's hemoglobin A1c (glycated hemoglobin) was found to be 11.6% (percent). The blood glucoses in the ER (emergency room) were 148 and 153. Blood pressure was 149/94. Her examination was unremarkable. The EKG (electrocardiogram) was remarkable for minimal voltage criteria for LVH. Her glucoses ranged between 111 and 206. Potential of hydrogen (pH) was 7.34. Bicarbonate was 25.9. Serum glucose was 161. Electrolytes were normal. Creatinine was normal. The patient was admitted and discharged two days later. The patient's discharge medications were metformin 750 mg BID.

The notes reported that the patient is not safe for discharge and is unable to be compliant with outpatient therapy.

No, the inpatient admission was not medically necessary.

Diabetes education consists of several components, such as, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1, 2).

Practice patterns differ depending on the availability of educators and resources. Whether a patient is hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the United States (3) that treat new onset type 1 diabetes admit their patients. According to the ADA (American Diabetes Association) statement on treatment of type 1 diabetes (4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education." However, that is not the case for type 2 diabetes. Indications for admission for new onset type 2 diabetes are more stringent and dependent upon the presence of symptoms such as ketosis, dehydration, hyperosmolarity, vomiting and inability to maintain hydration or severe metabolic/electrolyte abnormalities.

In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a two-to-three day admission to the hospital.

There are no randomized controlled trials comparing inpatient to outpatient diabetes education in type 2 diabetes (5-8).

In this case the patient had no metabolic abnormalities other than hyperglycemia. The patient was not started on insulin. The patient was monitored and educated to take her metformin. This could have been performed in the ER or as an outpatient visit. As such, the inpatient hospitalization was not medically necessary.