Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus, Type 2

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

According to the medical records, the patient is a female with a past medical history of asthma, chronic obstructive pulmonary disease (COPD), is on three liters (L) of oxygen via nasal cannula (NC) at home, has an immunocompromising illness and immunodeficiency disorder, and a past surgical history of colostomy. The patient presented to the emergency department (ED) with a chief complaint of dyspnea and abdominal pain. Prior to ED presentation, it was noted that someone was arrested in the patient's home and the patient acutely felt short of breath and called emergency medical services (EMS). EMS brought her to the hospital. Per EMS, the patient was on her home three L of oxygen NC, tachypneic to the 30's, but saturating in low 90's. She was placed on a non-rebreather (NRB) by EMS, with improvement in oxygenation to 100. The patient reported that she has had non-productive cough for several days. She also endorsed abdominal pain. On triage in the ED, her vital signs were: blood pressure (BP) -159/99, heart rate (HR) - 115, respiratory rate (RR) - 20, temperature - 37.5 Celsius, and oxygen saturation - 98% on NRB. Her lab results were notable for: white blood cells (WBC) - 8.9, glucose - 466, and hemoglobin A1C (Hgb a1c) - 13.5. Her urinalysis (UA) revealed greater that (>) 500 glucose, and ketones - 5. Endocrine was consulted for a new diagnosis of diabetes mellitus, type 2. Admission was recommended for insulin initiation. The patient was treated, and once medially stable, she was discharged home with diabetes management follow-up scheduled. 

According to Yan, J.W., et al (2018), "Objectives: Patients with poorly controlled diabetes mellitus may have a sentinel ED visit for a precipitating condition prior to presenting for a hyperglycemic emergency, such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS)."

The inpatient admission was medically necessary for this patient. The patient had uncontrolled type 2 diabetes with blood glucose of 450 with + 5 urine ketones with possible concurrent COPD exacerbation.  She had tachycardia and fever. Her comorbid conditions include immunocompromised status and COPD. She also was deaf and needed an interpreter. Although her bicarbonate was not low and did not meet criteria for DKA, there are other factors in her case that make inpatient admission admissible.

Stated by Dhatariya, K., et al (2020), "Diabetes is the most prevalent metabolic disorder and it is estimated to affect more than 460 million people globally. In the United States, 34.2 million Americans, or 10.5% of the population, have diabetes. Patients with diabetes have a 3-fold greater chance of hospitalization compared to those without diabetes. In 2016 in the U.S., there were over 7.8 million hospital stays for patients with diabetes. Hyperglycemia, defined as a blood glucose greater than 140 mg/dl [milligrams per deciliter] (7.8 mmol/l [millimoles per liter]), is reported in 22-46% of non-critically ill hospitalized patients. Extensive data indicates that inpatient hyperglycemia, in patients with or without prior diagnosis of diabetes, is associated with an increased risk of complications and mortality."

Also, stated by Rushakoff, R.J. (2019), "Appropriate inpatient glycemic management limits the risks of severe hypo- and hyperglycemia. Preventing and treating hyperglycemia reduces infections and minimizes fluid and electrolyte abnormalities. Specific glucose goals remain fluid..."   

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be overturned. The medical necessity is substantiated.