Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.


The patient has sickle cell trait and presented to the emergency department (ED) with a 1 week history of polydipsia and polyuria with dehydration. He had no complaints of pain while urinating, blood in urine or abdominal pain. This was his first episode. At his primary doctor's (PMD's) office, his blood glucose levels were 500 milligrams per deciliter (mg/dl), so he was referred to the ED. His activity levels remained unchanged since the onset of symptoms.

His vital signs at the time of presentation were heart rate (HR) 110, respiratory rate (RR) 20, blood pressure (BP) 108/73, temperature 98.6 degrees Fahrenheit, and oxygen saturation (O2 sat) 99% on room air (RA). The physical exam was unremarkable. The glucose level in the ED was 447, potential hydrogen (pH) 7.4, hemoglobin (Hgb) A1c 11.4%. The patient was admitted for further workup and management of diabetes with diabetic education. As the patient was not in diabetic ketoacidosis (DKA), endocrinology gave insulin orders as well as orders for Metformin twice daily (BID).

While admitted, the patient continued with good by mouth (PO) intake with insulin injections given after carb counting and bedtime with regular glucose monitoring as per plan by endocrine specialist. The endocrinologist reported further assessment necessary for final diagnosis of diabetes mellitus (DM) 1 versus DM2. At the time of discharge the patient's mother was comfortable with measuring point of care testing (POCT) glucose, giving insulin and calculating carbohydrates (carbs) and calories. The patient was cleared for discharge home and instructed to follow up with the PMD in 2-3 days and Endocrinologist in 6 days.

At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.

This patient presented with hyperglycemia and dehydration. He was not in diabetic ketoacidosis (DKA), nor did he have any signs of clinical instability evidenced by stable vital signs as well as no vomiting, diarrhea or altered mental status. He was able to tolerate by mouth (PO) at the outset. He did not have a significant amount of ketones in his blood. His blood pH was 7.4 which would not meet criteria for DKA. He was started on subcutaneous insulin, oral Metformin and a diabetic diet. He could have been managed at a lower level of care while he was on subcutaneous (SQ) insulin, a diabetic diet and receiving diabetic education.

The patient did not meet criteria for inpatient admission as he did not meet criteria for diabetic ketoacidosis (DKA) based on the potential hydrogen (pH) in his blood gas of 7.4. He did not meet the acidosis criteria outlined by Milliman Care Guidelines (MCG) Health Inpatient and Surgical care of Pediatric Diabetes. He did not meet inpatient criteria for hyperglycemic hyperosmolar state because he did not have any neurological dysfunction or serum osmolality greater than (>) 320. He did not meet criteria for hyperglycemia requiring inpatient care, as he did not have altered mental status, dehydration, vomiting or significant electrolyte abnormality such as hypokalemia, hyperkalemia or hypernatremia that was not responsive to outpatient and observation care treatment. For these reasons, inpatient level of care criteria were not met; therefore, an inpatient stay was not medically necessary.