Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Type 1 Diabetes Mellitus, Depression.
Treatment:  Pre-Planned Elective Admission-Inpatient Acute Rehabilitation.

The insurer denied the Pre-Planned Elective Admission-Inpatient Acute Rehabilitation.  The denial was overturned.

This is a female patient with a history of Type 1 diabetes x 6 yrs.  She has multiple outpatient education events with a diabetes team over that time.  Nevertheless, she has remained in poor control with a HgbA1c rising from 8.9% in mid-2019 to 11% and admission for diabetic ketoacidosis.  She is also known to suffer from depression associated with abnormal eating behaviors and excessive weight gain with weight percentile going from 88th percentile in early 2018 to 93th percentile in mid- 2019 with further increase between late 2019 and the beginning of 2020 to 94% percentile.  She has had visiting nurse service and home care in addition to her diabetes team education.  An admission to a chronic illness program was planned to improve her education and ability to self-monitor and to integrate with psychosocial support.  The insurer has denied this stating that:

"The medical notes did not show that the patient needed therapy to get back a function that was lost or not fully matured; the notes did not show that the patient needed to do 3 hours of skilled therapy per day for 5 days per week; notes did not show that the request was for at least two therapies (physical, occupational, speech/swallowing, prosthetic/orthotic use)."  They conclude that the services recommended could be provided through outpatient care and home care.

She is described as having depression and resorting to eating with adverse effects on both weight and diabetes control.  Eating disorders are a known adverse event in diabetes care requiring intervention to improve outcomes (1).

The content of a diabetes education program must include the content as listed below: 

"The following core content areas, including the AADE7 self-care behaviors, demonstrate successful outcomes:  1)  diabetes pathophysiology and treatment options; 2)	healthy eating; 3)	physical activity; 4)  medication usage; 5)  monitoring and using patient-generated health data (PGHD); 6)  preventing, detecting, and treating acute and chronic complications;  7)  healthy coping with psychosocial issues and concerns; 8)  problem solving.

It is crucial that the content be tailored to match individuals' needs and be adapted as necessary for age, developmental stage, type of diabetes, cultural factors, health literacy and numeracy, and comorbidities"(2). 

The rehabilitation program proposed presents a one-month intensive therapy outlining more than 3hrs/week in nutrition counseling, psychologic therapy, medication and disease specific therapy, physical and occupational therapy in addition to weekly family and psychological counseling.  Therapies which are unequivocally skilled therapies and needed as a part of diabetes education as well as needed to get this child back to normal functioning.  The goal here is to ensure she can integrate diabetes care into life functioning.  At the moment she clearly is not doing so with rising HgbA1c, multiple school absences and hospitalizations for out of diabetes control.

Therefore, intensive intervention is indicated to address these issues since diabetes education with her team, visiting nurse service and home care have not been able to achieve improved control, avoid eating disorders or even maintain school attendance.

Based on the above, the medical necessity for Pre-Planned Elective Admission-Inpatient Acute Rehabilitation is substantiated.  The insurer's denial is overturned.