Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male with a past medical history significant for diabetes mellitus Type 2, hepatitis C virus, and alcoholism who presented to the emergency department with complaints of chronic diarrhea.
He was initially seen in the emergency department, for evaluation of abdominal pain. Radiographic evidence of colitis was found, and the patient left the emergency department against medical advice. According to the records, the patient received a prescription for Ciprofloxacin which he did not pick up either.

He subsequently returned to the emergency department, and at the time of the initial evaluation, the patient complained of several months' history of multiple semi-formed watery stools five to six times a day on average.

The patient denied fever, chills, nausea, vomiting, abdominal pain, blood in the stool, malodorous stools. The patient also reported a 40-pound unintentional weight loss over the course of one year.
At the time of the initial evaluation, the patient was afebrile, blood pressure was 118/78, pulse rate 78 beats per minute (bpm), respiratory rate 18, oxygen saturation 98% on room air. The patient appeared to be a well-developed, well-nourished individual who was alert and cooperative, in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops.

On the abdominal exam, the patient had positive bowel sounds. The abdomen was soft, nondistended, nontender, without guarding or rebound. There were no masses. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that the patient's sodium was 125, potassium 4.7, chloride 91, bicarbonate 19, blood urea nitrogen (BUN) 11, creatinine 0.57, glucose 620. White blood cell count was 5.2, hemoglobin 12.5, hematocrit 35.7, platelets 195.
The patient was admitted to the hospital with a diagnosis of chronic diarrhea, hyperglycemia, chronic lactic acidosis. Another clinical diagnosis included transaminitis, and chronic alcoholism.

The patient was recommended to start taking Creon with each meal and snacks. Additional laboratory studies were sent for evaluation of diarrhea, the patient was recommended esophagogastroduodenoscopy (EGD) and colonoscopy.

During the hospital stay the patient was found to have uncontrolled diabetes mellitus. His Hemoglobin A1c came back greater than 14%.
Reportedly, the patient refused EGD and colonoscopy while in the hospital, therefore these studies were recommended as an outpatient.
During the hospital stay the patient remained in stable clinical condition, therefore he was discharged home with a prescription for Creon, and recommendations to continue to use insulin for his uncontrolled diabetes mellitus.

At the time of the discharge, the patient was recommended to follow up with his primary care physician, a gastroenterologist, and an endocrinologist. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole. 

The patient presented to the hospital with chronic diarrhea and weight loss which had been going on for several months.

At the time of the initial evaluation, the patient was afebrile and hemodynamically stable. The physical exam was reassuring without any alarming features.

However, the patient had some abnormalities in his lab work. The most prominent abnormality was severe hyperglycemia. The reported low sodium level was in fact related to pseudo-hyponatremia due to severe hyperglycemia. The corrected sodium level was 137 mEq/L, which was normal.

Despite hyperglycemia, there was no clinical evidence of severe dehydration or other significant electrolyte abnormalities. There was no evidence that the patient had diabetic ketoacidosis since the venous blood gas (VBG) revealed that the pH was 7.32 (normal). There was no clinical evidence that the patient had another glycemic emergency such as hyperglycemic hyperosmolar syndrome (HHS).

Taking into consideration these facts, the admission for monitoring the patient was reasonable to ensure better glycemic control, since the patient was unable to achieve reasonable glycemic control as an outpatient, however this did not require treatment at the inpatient level and could have been accomplished at a lower level of care status. The workup of his chronic diarrhea and weight loss could likewise have been performed at a lower level of care since there were no alarming features based on the results of his physical exam or laboratory studies justifying admission for evaluation of chronic diarrhea at the acute inpatient level of care.