Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay
The determination is upheld.

This is a patient with a past medical history significant for type 2 diabetes mellitus, dyslipidemia, and polysubstance abuse (including heroin, cocaine, tobacco) who presented to the hospital and requested detox. The review of systems was negative for chest pain, shortness of breath, headache, dizziness, syncope, abdominal pain, urinary symptoms.
Reportedly, the patient was on a Methadone taper before his presentation. According to the history and physical (H&P) note, when seen by the admitting physician the patient was irritated and did not answer questions properly.
On the physical exam, the patient was afebrile. Pulse rate was 99 beats per minute (bpm), respiratory rate 18 breaths per minute, blood pressure 120/77, oxygen saturation 98% on room air. The physical exam was unremarkable. On the neurologic exam, the patient was awake, alert, and oriented. He was able to communicate. The patient had normal muscle strength throughout and normal cranial nerves.
Laboratory evaluation revealed that his white blood cell count was 136, potassium 5.9, chloride 100, bicarbonate 27, blood urea nitrogen (BUN) 22.4, creatinine 1.48, and glucose 263. The white blood cell count was 10.3, hemoglobin 14.0, hematocrit 42.3, platelets 238 and troponin 0.11.
The patient was admitted to the hospital with diabetes mellitus, opioid dependence, dyslipidemia, cocaine use disorder, tobacco use disorder, and acute kidney failure. Uncontrolled diabetes mellitus was attributed to medical noncompliance.
The admitting physician stated that the patient's latest blood sugars were in the range between 366 and 397 and hemoglobin A1c was 11.9. The admitting physician stated that the patient's serum ketones were negative.
The admitting physician stated that the patient had already been on Methadone and planned to continue methadone treatments a part of the detoxification. At the time of admission, the patient was diagnosed with acute on chronic kidney disease. It was mentioned that the patient's baseline creatinine was 1.3.
The patient was started on intravenous fluids, and it was planned to monitor kidney function closely.
In the hospital, the patient was seen by an endocrinologist who stated that the patient had uncontrolled diabetes mellitus due to noncompliance. The endocrinologist recommended the continuation of treatment with insulin as well as podiatry and ophthalmology follow-ups as an outpatient.
On the next day after the day of admission, the patient's kidney function significantly improved, including the resolution of hyperkalemia. At the end of the hospitalization, the patient was discharged home in stable clinical condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
This patient presented to the hospital for detox. However, according to the records, there were no signs of withdrawal, and the patient was maintained on his usual dose of Methadone. At the time of admission, the patient had laboratory signs of acute kidney injury with hyperkalemia. However, he had no symptoms of hyperkalemia and no electrocardiogram (EKG) changes.
He had a slightly elevated troponin level, which was likely related to a mild degree of kidney insufficiency. As a result of the treatment with intravenous fluids and administration of Kayexalate, his kidney function normalized very quickly and the hyperkalemia resolved.
At the time of admission, the patient was diagnosed with uncontrolled diabetes mellitus. However, the review of the medical records clearly demonstrated that the patient had no evidence of glycemic emergencies such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. In addition, the patient did not require continuous infusion of insulin.
Taking into consideration all of this information, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care. Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Care could have been provided at a lower level.