Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypoglycemia.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

According to the medical records, the patient is a female with a history of hypertension, asthma, seizure, hypoglycemia and bariatric surgery. The request is for coverage of an inpatient stay. The coverage was previously denied, this is an appeal initiated by the hospital. The coverage was previously denied because the patient did not meet medical necessity criteria under the health plan.

The patient presented to the emergency department (ED) for hypoglycemia with associated dizziness, shaking, and diaphoresis. The patient reported glucose in the range of 30-50 and a seizure. The patient was found to have a glucose of 90 on arrival. Exam showed a normal mental status. The patient received fingersticks every 4 hours. Her blood sugar was 34 with symptoms and was corrected with juice. She was started on acarbose. Her glucose was controlled with diet modifications. 

An Inpatient admission was medically necessary. This is a patient with recurrent severe hypoglycemia, with documented low blood sugars, and reversal of symptoms after correcting. She has pathologic hypoglycemia, which increases mortality and morbidity risk. Her hypoglycemia is also complicated in the past by seizures. She requires the high intensity of monitoring and a workup in an inpatient setting. Denial of the hospital admission at an inpatient level should be overturned.

"The treatment regimen and glycemic goals should be reviewed and adjusted if needed. Patients should be instructed on how to manage hypoglycemia, either by the ingestion of carbohydrates if possible, or by parenteral glucagon or glucose. If the patient has hypoglycemia unawareness, a 2-to 3-week period of strict avoidance of hypoglycemia should be maintained, as hypoglycemia awareness will return in many patients. For individuals with type 1 diabetes and a history of serious hypoglycemia, the use of a personal continuous glucose monitoring device, sensor-augmented insulin pump therapy, or a hybrid closed loop system should be considered." (Desimone, ME. et al. 2018).

"Conclusions: We recommend evaluation and management of hypoglycemia only in patients in whom Whipple's triad--symptoms, signs, or both consistent with hypoglycemia, a low plasma glucose concentration, and resolution of those symptoms or signs after the plasma glucose concentration is raised--is documented. In patients with hypoglycemia without diabetes mellitus, we recommend the following strategy. First, pursue clinical clues to potential hypoglycemic etiologies--drugs, critical illnesses, hormone deficiencies, nonislet cell tumors. In the absence of these causes, the differential diagnosis narrows to accidental, surreptitious, or even malicious hypoglycemia or endogenous hyperinsulinism. In patients suspected of having endogenous hyperinsulinism, measure plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and circulating oral hypoglycemic agents during an episode of hypoglycemia and measure insulin antibodies." (Cryer, P. E. et al. 2009).

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.