Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  New Onset Diabetes Mellitus.
Treatment:  Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has no significant past medical history who was referred to the hospital from preoperative testing.  Reportedly, the patient was scheduled for a pilonidal cyst surgery, and during the preoperative evaluation, it was noted that his blood sugars were in the 500-600 range.  When seen by the admitting physician, the patient reported polydipsia and polyurea, which had been going on for two weeks.  The patient's review of systems was also positive for malaise and fatigue.

When seen by the admitting physician, the patient was afebrile, blood pressure was 130/84, pulse rate 102, respiratory rate 18, and oxygen saturation 98%.  The patient was awake, alert, and oriented times 3.  His head, eyes, ears, neck, throat (HEENT) exam was unremarkable.  Lungs were clear to auscultation bilaterally; breathing was not labored.  The abdominal exam was benign.  The patient was able to move all four extremities.  There were no focal deficits.

Laboratory evaluation revealed that the sodium was 128, potassium 4.7, chloride 93, bicarbonate 24, blood urea nitrogen (BUN) 9.0, and creatinine 0.64.  The initial glucose was 565.  Beta-hydroxybutyrate was within normal limits.  A urinalysis revealed massive glucosuria.

An electrocardiogram (EKG) demonstrated normal sinus rhythm with left atrial enlargement and nonspecific ST and T wave abnormalities.  The patient was admitted to the hospital with a diagnosis of new-onset of diabetes mellitus.  At the time of admission, he had hyperglycemia and pseudohyponatremia.  During the hospital stay the patient was started on insulin therapy, which led to an improvement in glycemic control.  At the time of the discharge, the patient was recommended to use long-acting insulin as well as Metformin.  In the hospital, the patient received diabetic education and was taught the insulin injection technique.  At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary at the acute inpatient level of care.  The American Diabetes Association Hospital Admission Guidelines for Diabetes are guidelines to be used for determining when a patient requires hospitalization for reasons related to diabetes.  Inpatient care may be appropriate in the following situations:  1) life-threatening acute metabolic complications of diabetes, 2) newly diagnosed diabetes in children and adolescents, 3) substantial and chronic poor metabolic control that necessitates close monitoring of the patient to determine the etiology of the control problem, with subsequent modification of therapy, 4) severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes, 5) uncontrolled or newly discovered insulin-requiring diabetes during pregnancy, or 6) institution of insulin-pump therapy or other intensive insulin regimens.

The review of the medical records demonstrated that the patient did not meet the criteria for the inpatient hospital admission.  Although, he was started on long-acting insulin once a day, this regimen could not be considered high intensity.  Care to ensure adequate glycemic control, provide diabetes education, and teach the patient insulin injection techniques could have been provided at a lower level.  Based on the hospital admission guidelines for diabetes described above, this patient had no life-threatening acute metabolic complications of diabetes.  This patient was a young adult and not a child or adolescent.  The patient also did not meet the other criteria listed above.  
The patient did not have significant electrolyte abnormalities.  The decreased sodium level represented pseudohyponatremia, which is common in cases of severe hypoglycemia; this was not a real hyponatremia.

Therefore, neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.  This patient was diagnosed with new-onset of diabetes mellitus and had significant hypoglycemia, but it was not associated with significant electrolyte abnormalities, severe dehydration, acute kidney injury, or other metabolic derangements that would necessitate admission at the acute inpatient level of care.