Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient Stay
The health plan denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a female with a past medical history significant for type 2 diabetes mellitus, depression, obesity, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), and right breast cancer who presented to the emergency department with complaints of right arm pain that started 2 days before the presentation. The patient stated that the arm became more swollen and painful. The patient attributed this to lymphedema. In the past, she had similar episodes that resolved without intervention. The patient was unable to identify any triggers. At the time of the initial evaluation, the patient denied any fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or diarrhea. Reportedly, the patient was noncompliant with her insulin regimen. She checked her blood sugars occasionally and stated that they were running around 300.

The patient was admitted to the hospital with a diagnosis of hyperglycemia. At the time of admission, the patient was initiated on basal and bolus insulin coverage. The arm and leg pain were attributed to chronic lymphedema and venous stasis. During the hospital stay, the patient underwent a computed tomography (CT) angiogram of the chest that ruled out pulmonary embolism. It showed some ground-glass attenuation, but the clinical significance of this finding was unclear.
As a result of the treatment provided in the hospital, the patient's blood sugars went down significantly to 200-300 range. In the hospital, she received wound care. Since the patient's clinical condition continued to improve, she was discharged home with home care.

The health plan's determination of medical necessity is upheld, in whole.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The review of the medical records demonstrated that neither the severity of the patient's condition nor the complexity of the services provided rose to an acute inpatient level of care.
The patient presented to the hospital with hyperglycemia, which was clearly related to medical noncompliance. At the time of the initial evaluation, there was no evidence that the patient had diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome. The review of the medical records clearly demonstrated that the patient had no evidence of profound dehydration or significant electrolyte abnormalities associated with hyperglycemia. There was no clear evidence of underlying infection or acute coronary syndrome. There was no need for continuous insulin infusion since the blood sugars came down after the administration of subcutaneous insulin. While in the hospital, the patient did not require advanced wound care for her chronic skin ulcers.