Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The medical records indicate the patient has diagnoses of Diabetes and Stage IV (Four) Chronic Kidney Disease. The patient presented to Brookdale Hospital via (through) ambulance after becoming confused, remaining in the shower for four hours, slurred speech and unsteady gait. The patient had a fingerstick glucose of 60, taken by Emergency Medical Services (EMS). The patient was given one (1) ampule of dextrose 50% (percent) (D50) by the emergency medical staff and the patient refused to go to the Emergency Department (ED), until four (4) hours later. 

The patient was taken to the emergency department and their glucose was in the 400s. At the time of presentation, the patient's potassium level was as high as 7.1 and later reduced to 5.6. A physical examination, at the time of presentation, revealed normal constitutional of head, eyes, ears, nose, and throat (HEENT), cardiovascular, pulmonary, abdominal, musculoskeletal, skin, general neurological, mental status, cranial nerve, sensory, motor, and coordination examinations.

The patient underwent a head computerized tomography (CT) scan, that was negative for acute changes. The patient was found to be hyperglycemic and was provided with insulin. The patient was hyperkalemic and blood pressure was elevated and creatinine was elevated over baseline. There is no evidence of diabetic ketoacidosis or hyperosmolar hyperglycemic state. The patient was admitted to treat hyperkalemia, hyperglycemia and acute kidney injury.

After stroke and intracranial bleed was ruled out the patient was treated with antihypertensives in addition to insulin. The patient was seen by nephrology for recommendations for managing the electrolytes. The patient's blood pressure was managed with antihypertensive medications. The patient improved during the hospitalization with an improvement in their electrolytes and blood pressure. 

The patient did not require an acute level of care and could have been treated at the emergency department or observation level.

The patient presented with hypoglycemia, followed by a hyperglycemia and hyperkalemia. The patient had a change in mental status that was attributed to electrode abnormalities (i.e. metabolic encephalopathy). An acute intracranial process was ruled out with a negative head CT (computerized tomography) scan. The provision of hydration, insulin, and antihypertensives can be provided in the emergency department or observation setting. Rapid improvement was expected and did occur. The patient had no evidence of any neurological syndrome independent of the hyperglycemia and electrolyte abnormalities. There is no expectation of decompensation with appropriate treatment. The patient had hypertension that can be rapidly treated with antihypertensives. Hyperkalemia can likewise be treated with medications to decrease with treatment of the diabetes and with medications to treat the elevated creatinine that did not require an acute level of care.

The patient did not require any intensive neurological, hemodynamic, pulmonary or cardiac monitoring. There was no need for further urgent intervention with decompensation as the patient was expected to improve not decompensate. The patient did not have any acute care needs or acute inpatient care needs. The patient could have been treated in the emergency room or under observation, with discharge once the hyperglycemia, eye, hyperkalemia and hypertension were treated. 

There was, therefore, no specific medical need for an acute level of hospitalization and care could have been performed in the emergency department/observation level.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.