Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperosmolar Hyperglycemic Syndrome (HHS).
Treatment inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.	
The denial is overturned.

The patient is an adult male with a past medical history of congestive heart failure, chronic systolic heart failure, diabetes mellitus, dilated cardiomyopathy, hypertension, mixed hyperlipidemia, and a stroke. The patient was sent from the clinic for hypotension and hyperglycemia that was noted to be severe. The physical examination was normal. The patient presented to the Emergency Department (ED) with a high reading on fingerstick. The patient was asymptomatic in the ED. The patient denied a headache, dizziness, chest pain, shortness of breath, and had no abdominal or flank pain. There were no urinary complaints. The patient's blood pressure was 93/62. The patient clinically did not appear to be in diabetic ketoacidosis. There were no clinical signs to suspect infectious etiology. The patient was then admitted to the medicine unit for management of hyperosmolar hyperglycemic syndrome. The patient was seen by Psychiatry service and following evaluation, he was deemed to be sufficiently capable of making an informed decision, recognizing risks and benefits of treatment and nontreatment, and was competent to make a rational medical decision to refuse continuing admission and recommended medical treatment and leave the hospital Against Medical Advice.

Hyperosmolar hyperglycemic state (HHS) is a life-threatening medical emergency manifested by marked elevation of blood glucose and hyperosmolarity with little or no ketosis. (1) Initial laboratory findings in patients with HHS include marked elevations in blood glucose levels (greater than 600 milligrams/deciliter [mg/dL] [33.3 millimoles/liter (mmol/L)]) and in serum osmolarity (greater than 320 milliosmoles/liter [mOsm/L] of water [normal = 290  5]. (1) These findings were objectively documented in this patient; therefore, the diagnosis of HHS is not in question.  The incidence of HHS is estimated to be <1% (percent) of hospital admissions of patients with diabetes. The reported mortality is about 10 times higher than the mortality rate in patients with diabetic ketoacidosis (DKA). (2)

The inpatient admission was considered medically necessary for this patient. Consistent with current clinical practice guidelines, HHS treatment begins with intensive monitoring of the patient and laboratory values, especially glucose, sodium, and potassium levels. Vigorous correction of dehydration is critical, requiring an average of 9 L (liter) of 0.9% saline over 48 hours in adults. After urine output is established, potassium replacement should begin. Once dehydration is partially corrected, adults should receive an initial bolus of 0.1 units of intravenous insulin per kg (kilogram) of body weight, followed by a continuous infusion of 0.1 units per kg per hour (or a continuous infusion of 0.14 units per kg per hour without an initial bolus) until the blood glucose level decreases below 300 mg per dL. (1) The above management cannot be conducted in an outpatient environment, and typically requires an intensive care/critical care environment due to the frequency of clinical monitoring and continuous IV (intravenous) insulin infusion. (1) 

HHS is a serious complication of poorly controlled diabetes which carries a high mortality rate that reaches 40%. (3)

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient by denying coverage for inpatient hospital admission.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.