Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia, Seizure, Facial laceration, Abrasion of the neck
Treatment: Inpatient stay
The insurer denied coverage for the inpatient stay.
The denial is upheld. 

This is a male patient with a history of type 1 diabetes mellitus on insulin pump who was brought to the Emergency Department (ED) for hypoglycemia and possible seizure. The patient fell as a result of the seizure and suffered forehead lacerations which were sutured in the ED. Prior to the ED admission, as per the patient's fiance, the patient's morning blood sugar was 40 and his repeat blood sugar was noted to be low. The patient ate something and then proceeded to have a seizure and was incontinent of urine at that time. In the ED, a full ED assessment was performed and it was determined that the patient required continued acute care. The patient was admitted for hypoglycemia, seizure, facial laceration, and abrasion of the neck. The patient was discharged after treatment and once medically stable.

As per Spanakis et al. (2018), "hypoglycemia, caused by treatment with a sulfonylurea, a glinide, or insulin coupled with compromised defenses against the resulting falling plasma glucose concentrations, is the limiting factor in the glycemic management of diabetes. It causes recurrent morbidity in most people with type 1 diabetes mellitus (T1DM) and many with advanced type 2 diabetes mellitus (T2DM) and is sometimes fatal; it limits maintenance of euglycemia over a lifetime of diabetes; and it impairs physiological and behavioral defenses against subsequent hypoglycemia." Thus, literature, such as International Hypoglycaemia Study Group (2015) indicates the importance of minimizing hypoglycemia which "includes acknowledging the problem; considering each risk factor; and applying the principles of intensive glycemic therapy, including drug selection and selective application of diabetes treatment technologies. For diabetes health-care providers treating most people with diabetes who are at risk for or are suffering from iatrogenic hypoglycemia, these principles include selecting appropriate individualized glycemic goals and providing structured patient education to reduce the incidence of hypoglycemia. This is typically combined with short-term scrupulous avoidance of hypoglycemia, which often will reverse impaired awareness of hypoglycemia. Clearly, the risk of hypoglycemia is modifiable."

According to Yeoh et al. (2015)'s review, there is "evidence for the effectiveness of a stepped-care approach in the management of patients with [Impaired awareness of hypoglycemia (IAH)], initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need." 

In this case, based on the medical records and the literature, the inpatient admission was not medically necessary for this patient. The patient's seizure was secondary to his iatrogenic hypoglycemia and was treated and resolved in the ED. The patient received appropriate emergency care for his injuries and imaging was negative for severe skeletal or intracranial injuries. The patient was stable to be safely monitored at a lower level of care, such as observation bed in the ED with neuro checks. Once stable, the patient's care could have been closely followed-up in the outpatient setting, including his diabetes education and management.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.                                   

Based on the above, the medical necessity for the inpatient stay is not substantiated. The insurer's denial should be upheld.