Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia 
Treatment: Hospital admission
The insurer denied coverage for hospital admission.  
The denial is overturned. 
The patient is a male with Type 2 DM (diabetes mellitus), HTN (hypertension), CKD (chronic kidney disease) stage 3, CAD (coronary artery disease), prostate cancer, and hyperlipidemia. He presented to the Emergency Room (ER)  with concerns of mental status changes and hypoglycemia. Current diabetes regimen is Lantus at bedtime which he took the night before. He felt unwell and checked his blood sugar which was 24. Symptoms included feeling confused and tremors. He did try and correct his low blood sugars with orange juice but his blood sugar did not respond. EMS (emergency medical services) was called, finger stick glucose of 26 noted, and he was given an ampule of dextrose 50 (D50).  His initial finger stick glucose was 46 in the ER. Bloodwork revealed white blood cell (WBC) count 8.0, hemoglobin 12.8, blood urea nitrogen (BUN) 54, creatinine 2.84, serum glucose 93, and troponin 0.02. Electrocardiogram (EKG) showed sinus bradycardia with 1st degree AV block. X-rays of his chest were unremarkable. He was treated with intravenous (IV) fluids. Repeat finger stick glucose in the ER showed glucose of 300. He was admitted to the hospital for hypoglycemia. Endocrinology was consulted. The patient's medications were adjusted. The patient did not have any further episodes of hypoglycemia overnight and was discharged.
"Chronic kidney disease (CKD) is an independent risk factor for hypoglycemia, and augments the risk already present in people with diabetes [7,8,9].  In addition, CKD imposes restrictions on antidiabetic therapeutic options and increases the risk of cardiovascular disease and death [7,10,11,12,13]." (Alsahli et al 2015).

"Diabetes mellitus is the leading cause of CKD in the US, with estimates suggesting that close to 50% of diabetes patients show evidence of CKD [10,11]. Diabetes is also often difficult to control in the CKD population; several antihyperglycemic agents are contraindicated in CKD patients, and the pharmacokinetics of others, including insulin, change with declining glomerular filtration rate (GFR) [Lovre et al 2018]."

"Hypoglycemia is a major potential adverse effect of diabetes mellitus (DM) treatment with glucose-lowering drugs, such as insulin or oral medications. The presentation of hypoglycemia can be mild, involving symptoms such as dizziness, diaphoresis, and/or disorientation, or severe, involving symptoms such as neuroglycopenia, which represents a medical emergency and causes permanent brain damage if not detected and treated early. Hypoglycemia can also activate the adrenergic response, resulting in vascular hypoperfusion, cardiac arrhythmia, or even sudden death [13]." A post hoc analysis of data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study found that hypoglycemia was associated with a higher risk of subsequent mortality, which did not differ between intensive and conservative glycemic control groups.  
The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.
The carrier's denial of coverage for the hospital admission is overturned. The medical necessity is substantiated.