Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is overturned.

The patient is a male with a medical history significant for asthma, obesity, non-alcoholic fatty liver disease, hyperlipidemia, and type 2 diabetes. He was sent to the emergency department (ED) from the clinic with elevated hemoglobin A1C (hgbA1C) despite treatment with Metformin and Insulin. He reported several weeks history of polyuria and polydipsia. His vital signs included temperature 36.4, heart rate 93, respiratory rate 20, and blood pressure 117/68. His examination was significant for no distress, moist mucous membranes, clear lungs, non-focal neurologic examination.
Endocrinology recommendations included admission for management of hyperglycemia and diabetes education, as well as an Insulin regimen with target glucose of 100. He had threatened suicide a week prior when he was denied a video game and had remote history of auditory hallucinations, so he was also evaluated by Psychiatry and cleared. He was treated with a Normal Saline bolus and Lispro and Insulin for bedside glucose 348.   
Admission orders included glucose checks, pediatric carbohydrate consistent diet, Insulin regimen, continued Metformin, additional lab tests, and plans for multiple subspecialty outpatient appointments. There were also plans to start Trulicity to help with both Insulin production and weight loss. Over the course of his hospital stay, his blood sugars improved, and he was able to wean from bolus Insulin while continuing basal Insulin in conjunction with Metformin and Trulicity. Education was complicated by his mother's inability to read or recognize numbers, but she was taught to recognize the reading of low blood sugar on the meter and could understand when to check for urine ketones. 

Diabetes mellitus is a chronic metabolic disease characterized by hyperglycemia. There are three basic types, gestational diabetes, type I diabetes, and type II diabetes. In type I diabetes, Insulin secretion is deficient as a result of damage to pancreatic islet cells. Type II diabetes occurs when tissues in the body develop Insulin resistance. Gestational diabetes occurs with pregnancy. Type I diabetes is the most common metabolic disorder of childhood and adolescence, with peak incidence at 5 to 7 years of age, and at the time of puberty. Males and females are equally affected, except in low risk populations where there is a slight increase in females. A number of genes have been identified in type I diabetes, and environmental factors also play a role. Insulin is essential for storage and utilization of cellular fuel. In the normal state, Insulin levels increase and decrease corresponding to intake of food. Without Insulin, tissues cannot use nutrient fuel. Hyperglycemia and catabolism result, with breakdown of fats and formation of ketone bodies, with accumulation of ketoacids.
Clinical presentation is governed by degree of hyperglycemia and development of ketoacidosis. Hyperglycemia produces an osmotic diuresis, with progressive dehydration. Accumulation of ketoacids results in development of metabolic acidosis. Complications of uncontrolled hyperglycemia include diabetic ketoacidosis (DKA) with risk of cerebral edema, and nonketotic hyperosmolar coma. Management of type I diabetes involves administration of exogenous Insulin, either by intermittent subcutaneous injections or Insulin pump therapy, as well as glucose monitoring and lifestyle changes. 

It took the full duration of his hospital stay to achieve adequate glucose levels, introduce another oral medication to his regimen, determine the appropriate combination of oral hypoglycemic agents and Insulin, and most importantly, adequately educate the family. It was particularly difficult because his mother was illiterate, and he had some mental health challenges.