Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 1 diabetes mellitus
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a female patient with a history of type 1 diabetes mellitus who was brought to the Emergency room (ER) by Emergency Medical Services (EMS) after being found unresponsive by a relative. Prior to the incident, as reported by the patient, the patient was feeling light-headed, so she ate some crackers and 4 sugar cubes. The patient's blood sugar continued to decline. The patient did not remember passing out. The patient's blood glucose was reportedly 50 by the EMS. The patient presented with 1-day history of nausea and vomiting in the setting of hypoglycemia at presentation to the ER. The patient was admitted for syncope secondary to hypoglycemia. Per the attending physician (AP), the patient required inpatient care due to hypoglycemia and nausea/vomiting and need for serial finger-stick glucose (FSG) and intravenous (IV) medication. The patient's FSG in the triage was 65. The patient had intrathecal insulin pump placed a day prior to this ER admission. Endocrinology was consulted. The patient was discharged after treatment. 

According to Seaquist et al. (2013), the prevention of hypoglycemia involves assessing for risk factors and tailoring treatment regimens to reduce risk. At each visit, the provider should inquire about any: Low measured glucose levels; Episodes requiring the assistance of another person; Episodes of symptoms consistent with hypoglycemia. All self-monitoring of blood glucose (SMBG) or continuous glucose monitoring (CGM) data that are available should be reviewed and the frequency and details of any recognized episodes of hypoglycemia determined. The insulin regimen is adjusted based on glucose patterns, with an eye to reducing hypoglycemia, while at the same time achieving target glucose and A1C [blood test] levels. Reducing the risk of hypoglycemia while maintaining or improving glycemic control involves application of the following principles: Patient education and empowerment; Frequent SMBG (usually with fingerstick measurements or with CGM [CGM primarily in type 1 diabetes or high-risk type 2 diabetes patients]); Individualized glycemic goals; Flexible and rational insulin (and other drug) regimens; Ongoing professional guidance and support.

Little et al. (2018) states that there is increasing evidence that structured patient education focused on implementation of flexible insulin therapy can reduce the incidence of severe hypoglycemia. As per the Food and Drug Administration (FDA) (2019) release: For the treatment of hypoglycemia in a person with impaired consciousness and no established IV access, the FDA suggests the immediate administration of glucagon, rather than waiting to establish IV access. Administration of glucagon will usually lead to recovery of consciousness within approximately 15 minutes, although it may be followed by marked nausea or even vomiting. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient could have been stabilized in the ER and then discharged with a glucagon pen or inhaled glucagon to be used at home to treat for severe hypoglycemia which is standard of care for diabetes management. The patient's insulin pump settings could have been evaluated and adjusted as an outpatient by her endocrinologist. The patient's diabetic education can be provided with close outpatient follow-up with her primary care doctor and/or endocrinologist. The patient's care could have been safely provided in these lower levels of care. The health plan acted 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 not substantiated. The insurer's denial should be upheld.