Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Hypoglycemia

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

According to the medical records, the patient has a history of bipolar disorder, type 2 diabetes mellitus (DM), hyperlipidemia, hypertension, hypothyroidism and thyroid surgery.  The patient presented to the Emergency Department (ED) via ambulance with complaints of weakness and collapse. He received a 50% (percent) dextrose (D50) injection enroute to the ED for a blood glucose level of 41. He recently started Ozempic injections in addition to glyburide for DM management but did not have a glucometer for blood sugar (BG) monitoring. While in the ED, he ate a full dinner and intravenous fluids with 2 additional D50 injections were administered. His blood sugar continued to remain low despite treatment. The patient was admitted for further hypoglycemia management with finger stick monitoring every 2 hours until his blood sugar stabilized. As the patient maintained a good appetite, intravenous fluids and D50 injections were discontinued. He was monitored for 48 hours during which time his blood sugar remained within normal limits. The patient was medically cleared for discharge. All instructions and follow up appointments were explained and provided to the patient. He received a glucometer to monitor his blood sugar levels as an outpatient.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient      

The inpatient admission is considered medically necessary for this patient. The claimant had severe hypoglycemia due to his diabetes medications with a serum BG of 50 or less with neurologic symptoms.  Investigation to the cause of hypoglycemia is necessary including adjustments of medications and proper education of the patient to ensure this does not happen again. 

Severe hypoglycemia requires the assistance of another person to actively administer carbohydrate, glucagon, or other resuscitative actions. In patients with IV (intravenous) access; patients already in the ED or hospital can usually be treated quickly by giving 
25 of 50 percent glucose (dextrose) IV and then monitored.

In patients without IV access; Glucagon is available for the treatment of hypoglycemia in a person with impaired consciousness and no established IV access. Administration of glucagon (subcutaneous, intramuscular, or nasal) will usually lead to recovery of consciousness within approximately 15 minutes, although it may be followed by marked nausea or even vomiting.

"Time to treatment after identification was faster when identified by care testing vs (versus) serum sample result. Time to repeat BG in the ED was relatively quick but did increase over time. About one-third of patients had refractory or recurrent hypoglycemia and infection was associated with this occurrence. Lack of dextrose containing intravenous fluid was associated with the incidence of recurrent hypoglycemia." (Bilhimer et al 2017)

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.