Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type II Diabetes

Treatment: Inpatient Hospital Admission

The insurer denied coverage for Inpatient Hospital Admission

The denial is overturned 

This patient is female diagnosed with new onset of diabetes. This request is for Inpatient Hospital Admission.  As reported, the patient had no significant past medical history. The patient presented to the Emergency Room (ER) with complaints of polydipsia and polyuria. The patient was found to have an elevated glycated hemoglobin level (HbA1c) of 11.3 at the pediatrician's office. The patient had increased thirst with water drinking, increased urination with enuresis, weight gain and increased snacking. The patient was sent in by her primary medical doctor (PMD) for hypoglycemia. The patient's physical examination was significant for acanthosis nigricans, obesity and eczema. The patient was admitted to the Pediatric Endocrinology Service with new-onset diabetes. The patient was not in diabetic ketoacidosis. The patient's urinalysis (UA) revealed glucose with no ketones. The patient's connecting peptide (C-peptide) was 5.63. The patient's other labs were within normal limits (WNL). The patient was diagnosed with likely Type 2 diabetes with antibodies pending. The patient was started on an insulin regimen with basal and short-acting insulin which was adjusted as indicated. The patient's glucose levels were tested and corrected as indicated. Diabetes education was provided. The patient was discharged on a carbohydrate counting regimen: target 100; insulin sensitivity factor (ISF) was 1:30 and insulin-carbohydrate ratio (ICR) was 1:8 with short-acting Insulin Humalog and long-acting insulin 25 units of Basaglar daily. The patient was discharged after a period of medical stability.

According to the American Diabetes Association (ADA) statement on treatment of diabetes,4  hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  In symptomatic diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3 day admission to the hospital. 

In this case, the patient is a child who presented with symptomatic onset diabetes requiring insulin initiation. The patient received insulin with dose adjustment as well as diabetes education for the patient and the family for all aspects of diabetes education. For symptomatic diabetes outpatient management is not appropriate. The request is consistent with generally accepted standards of medical practice and is therefore, considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the Inpatient Hospital Admission is substantiated.  The insurer's denial should be overturned.