Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/ Diabetes
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer upholds the health determination in whole.

The patient has a past medical history significant for coronary artery disease, non-ST elevation myocardial infarction (NSTEMI), hyperlipidemia, hypertension, diabetes mellitus (DM), cerebrovascular accident (CVA), and schizoaffective disorder who presented to the hospital with complaints of substernal chest pain that had been going on for one hour. Reportedly, the patient was given nitroglycerin by Emergency Medical Services. When  seen in the emergency department the patient denied chest pain but complained of vulvar rash, pruritus, increased frequency of urination, and some incontinence. Reportedly, the patient was noncompliant with medications for over 1 month. The review of systems was negative for fever, chills, chest pain, palpitations, shortness of breath, headache, dysuria, nausea, vomiting, and diarrhea. Reportedly, the patient was non-cooperative with the admitting physician. In the emergency department, the patient received treatment with intravenous fluids, insulin. The patient had an erythematous vulvar rash with excoriations and mild tenderness to palpation in the epigastric area. The rest of the physical exam, including the neural exam, was unremarkable. The patient was awake, alert, and oriented. The patient was admitted to the hospital with a diagnosis of Hyperosmolar Hyperglycemic State due to uncontrolled diabetes mellitus. The patient received treatment with intravenous fluids as well as subcutaneous insulin injections and was continued on her home regimen of medications for her other chronic medical problems.
The hospital stay was not medically necessary for this patient at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to an acute inpatient level of care.
The hyperosmolar hyperglycemic state that was mentioned as the main diagnosis in this case, is a metabolic complication of diabetes mellitus (DM) characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness.
The review of the medical records demonstrated that the patient had no evidence of HHS. There was no evidence of profound dehydration, and despite the erratic behavior, the patient was awake, alert, and oriented times 3. Even though the patient's blood sugars were high, there was no evidence of diabetic ketoacidosis. This patient had uncontrolled diabetes mellitus due to medical non-compliance.
During the hospital stay, the patient received treatment with fluconazole because of vulvar candidiasis.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Admission at a lower level of care was reasonable to ensure improvement in the level of hyperglycemia, and to encourage adherence to medical care including a regimen of the diabetes medications. Considering the patient's history of schizoaffective disorder and erratic behavior that was present at the time of admission, a short admission at a lower level of care was absolutely appropriate.