Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This is an adult male diagnosed with hyperglycemia (new onset of diabetes) and diabetic ketoacidosis (DKA). The patient has a history of hypertension and coronary artery disease (CAD) post 2 drug eluting stents. The request is for coverage of admission.

The patient presented to the emergency room (ER) with hyperglycemia. He has been having symptoms of polyuria and polydipsia and his finger stick glucose was over 500.
He had lower leg cramping and generalized sleepiness. 

Labs: Glucose 678, Sodium 125, Potassium 4.5, Chloride 91, bicarbonate 21, beta hydroxybutyrate 3, lactate 1.4, positive blood ketones, potential of hydrogen (PH) 7.36 which then dropped to 7.3. Urinalysis: greater than (>) 1,000 glucose, Ketones 40.

The patient was treated with intravenous (IV) fluids and insulins. The patient received diabetes teaching. 

His finger stick glucose improved to 269 by discharge.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1-5). 

Practice patterns differ depending on the availability of educators etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75 percent (%)) of medical centers in the US(6) that treat new onset diabetes admit their patients. According to the American Diabetes Association (ADA) statement on treatment of diabetes(7), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  In  diabetes, the initial hospitalization is to educate the patient and the family in self injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 1-3 day admission to the hospital(8-11). 

The patient was admitted because he had hyperglycemia and diabetic ketosis needing insulin initiation. 

The patient met the criteria for the diagnosis of new onset diabetes with ketosis based on positive blood ketones, urine ketones 40, beta hydroxybutyrate 3. The patient also had hyponatremia. The patient had a new onset of diabetes and required diabetic education.

The admission is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.