Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male with a past medical history significant for asthma, cerebral palsy, diabetes mellitus, emphysema, and hypertension who presented to the hospital with complaints of generalized weakness and polyuria. The patient stated that his symptoms started on the day of the presentation. He did not take his insulin that day.
The patient denied fever, chest pain, cough, weight loss, rash, urinary symptoms, or gastrointestinal (GI) symptoms. The patient was independent at the baseline.
When seen by the admitting physician, the patient was afebrile. Blood pressure was 146/94, pulse rate 98 beats per minute (bpm), respiratory rate 18 breaths/minute, oxygen saturation was 99% on room air.
The patient was awake and morbidly obese. He did not look ill-appearing, or toxic. He had poor dental hygiene. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 6.71, hemoglobin 13.5, and platelets 167. Sodium was 129, potassium 5.3, chloride 86, blood urea nitrogen (BUN) 10, creatinine 1.3, and glucose was greater than 600. Calcium was 10.5. Venous blood gas revealed normal potential hydrogen (pH) of 7.379. The hemoglobin A1c (glycated hemoglobin) was over 15.
The patient was admitted to the hospital with a diagnosis of uncontrolled diabetes mellitus. It was reported that the patient was non-compliant with his medications.
He received treatment with intravenous fluids as well as intravenous insulin. At the time of admission, the patient was placed on basal insulin, and Accu-Cheks were initiated. The admitting physician stated that the was no evidence of diabetic ketoacidosis (DKA). During the hospital stay, the patient received treatment for hyperkalemia. Subsequently, his repeat potassium level came down to 3.7. In the hospital, the patient remained in stable clinical condition and was transitioned to outpatient care.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

According to the nationally accepted standards of care, admission at the acute inpatient level of care is usually indicated in certain cases of diabetic ketoacidosis, hyperglycemic hyperosmolar state, and also when patients present with hyperglycemia associated with hemodynamic instability, severe or persistent altered mental status, severe or persistent dehydration, severe or persistent vomiting, significant electrolyte abnormalities that persist despite observation care treatment, or when glucose levels are persistently too high for the next level of care or not sufficiently stable despite observation care.
In this specific case, the patient presented with very high blood sugars, which measured over 900. Despite receiving adequate treatment, the patient's hyperglycemia persisted.
It was clearly indicated in the progress note written that the patient's blood sugars continued to be in the 400 range. Persistent hyperglycemia was a significant risk factor for worsening dehydration and further electrolyte abnormalities.
Therefore, in accordance with nationally accepted standards of care, the admission at the acute inpatient level of care was completely justified to achieve adequate glycemic control and provide patient education.