Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes.

Treatment: inpatient hospital services.

The insurer denied coverage for inpatient hospital services.

The denial is overturned.

The patient is a male with a history of attention deficit hyperactivity disorder (ADHD) and nonaccidental traumatic pancreatic transection requiring partial pancreatectomy at an early age. He presented to the Emergency Department (ED) with elevated blood glucose after months of dry mouth, polydipsia, polyphagia, and days of generalized weakness and abdominal pain. In the ED, his glucose was 452 with a sodium of 129 and urine glucose of greater than 1000 and urine ketones of 15. He was given a normal saline bolus and was given long-acting insulin of 30 units and placed on sliding scale insulin and Metformin. The patient was admitted for diabetes education and dietary education and adjustment of his insulin doses. He was monitored 4 times a day. Levemir and Metformin were titrated upward. He was taught how to check his blood sugars and how to treat hypo and hyperglycemia. Glucoses improved overnight but were still in the 200-300 range. Later, his glucoses were 198 and 199. His sliding scale started at 150 with 3 units. The patient was discharged home after completion of diabetes education and improvement of his sugars.

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, 2) 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 United States (3) that treat new onset type 1 diabetes admit their patients. According to the American Diabetes Association (ADA) statement on treatment of type 1 diabetes (4), 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 children and adolescents, it is often unclear if the patient has type I or type 2 diabetes until the antibodies return 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 2-3-day admission to the hospital. (5-8) 

The patient had symptomatic diabetes and needed to be admitted for diabetes education including insulin injection, glucagon injection, nutrition education, treatment of hyperglycemia and hypoglycemia. The patient also needed to get his sugars under control and titrate up his insulin. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient as the request is medically necessary. 

The insurer's denial of coverage for inpatient hospital services is overturned. Medical necessity is substantiated.