Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is overturned. 

The patient is a male with history of diabetes (unknown type, diagnosed about 1 year prior) who was sent to the emergency room (ER) from an outpatient clinic where he was found to have hyperglycemia. His diabetes was diagnosed at routine screening for participating in school sports. He was prescribed Metformin 500 milligrams (mg) twice daily (BID) but reports intermittent adherence. Mother also reports that his finger stick glucose (FSG) is too high to register but he refuses to go to the ER. The patient states he has never received insulin prior to day of presentation. He endorsed a 2-3 week history of polyuria, polydipsia and fatigue. He went to clinic to refill his Diabetes Medication(DM) medications where he was found to have FSG of 491 and hemoglobin  A1c was 15. He was given 8 units of insulin, but he had persistently high glucose after the dose of insulin as well as ketones in his urine, so he was referred to the ER.

On arrival to the ER, he was afebrile with stable vital signs. He was found to be hyperglycemic with FSG 247 and with acute kidney injury (AKI) with creatinine of 1.33 but he was not in diabetic ketoacidosis (DKA) (pH 7.34, bicarb 38). Labs were also significant for elevated beta-hydroxybutyrate, mild hyponatremia and mild hypochloremia. He received 1 normal saline (NS) fluid bolus and was transferred to admitting hospital for inpatient management and diabetes education. He was admitted for rehydration, to start insulin regimen and for diabetes education. He was started on a basal bolus insulin regimen per endocrine with Lantus 22 units (U), and Humalog medication was adjusted through the hospital stay and at the time of discharge (D/C) his parameters were target 100 carbohydrate (CHO) 1:10 and insulin sensitivity factor (ISF) 1:32. He was started on maintenance intravenous fluids (MIVF) with NS. As his by mouth (PO) intake and AKI improved, IVF were weaned off. Metformin was held during hospital stay. New-onset DM labs were sent and revealed HgbA1c greater than (>)14.0. Overnight he had one low blood glucose (BG) probably due to the fact that he did not finish the food he was covered for. He stated he felt dizzy and was unable to walk. BG improved with juice. Labs notable for normalized creatinine. Exam was unremarkable. The family was educated, and patient felt comfortable with checking BG, administering insulin and following sliding scale. He was then deemed stable for discharge. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole. 

In this situation, it would be in the best interest of the patient to admit to inpatient level of care to monitor his kidney function while providing IV hydration as well as to investigate the reason for his chronic poor control. This patient would need evaluation to ensure there are no psychosocial barriers responsible for his noncompliance as well as intense diabetes education and commencement of a new management plan. After being started on a new insulin regimen he had an episode of hypoglycemia down in to the 30's on the night prior to discharge. This patient met criteria for admission as he had Hgb A1c levels >100% of normal. The American Diabetes Association (ADA) states admission is necessary to "determine the reason for the control problems and to initiate corrective action". For this patient it included starting subcutaneous (SQ) insulin with a sliding scale and carb counting. For these reasons, inpatient hospital admission was medically necessary for this patient.