Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis (DKA) and cellulitis. 
Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial is reversed. 

This patient is a male with past medical history of type 1 diabetes, asthma, COPD, HTN, high cholesterol, arthritis and an active smoker who presented to the ED at with complaints of feeling dizzy, weak, and having pain in the right elbow. As per the ED triage note the patient was afebrile. He was in the wound clinic today and he felt dizzy and weak and he was sure that it was his sugar. His blood glucose was 536. As per the History of Present Illness (HPI) the patient stated his elbow is messed up and his sugar is high. He had a recent right toe amputation and hence sometime his balance is off. He reported that a week prior he lost his balance and scraped his right elbow. This started to get red, swollen, and warm with whitish discharge. He stated that for the past week he had been feeling weak, lightheaded and intermittently felt like he would pass out. He was complaining of high sugar's at home - in the 500's. He was admitted. His Hemoglobin A1c (HbA1C) was 10.2. Surgery was called for I and D of the abscess. He was also given insulin. The patient tolerated the procedure well and had frequent wound care. He continued on IV antibiotics and on insulin. He was discharged on oral antibiotics and instructions to follow up with the wound care clinic. 

Based upon the information provided, the acute inpatient admission is approved as it was medically necessary for in-patient care as the patient had a cellulitis and poorly controlled diabetes. The patient did need to be kept in the hospital as the diabetic management was an issue that did need to be addressed as an inpatient issue. The patient's HbA1C was 10.2 as well as blood glucose of greater than 500 upon presentation. Therefore, the inpatient admission was necessary. 

According to MCG Health Inpatient and Surgical Care 23rd Edition Cellulitis ORG: M-70 (ISC) Clinical Indications for Admission to Inpatient Care: Admission is indicated for 1 or more of the following: Failure of outpatient therapy as indicated by ALL of the following: Progression or no improvement after adequate trial (minimum of 48 hours, with longer period for stable lower extremity infection), Adequate antibiotic regimen as indicated by use of 1 or more of the following: First-generation cephalosporin (e.g., cephalexin), Antistaphylococcal penicillin (e.g., dicloxacillin), Penicillin-allergic patient regimen (Clindamycin, extended-spectrum fluoroquinolone, or doxycycline), Resistant organism (e.g., Methicillin-resistant Staphylococcus Aureus) regimen. Outpatient intravenous therapy is not appropriate due to 1 or more of the following: It was tried and was not successful (e.g., progression of infection), It is not available or cannot be arranged in a clinically appropriate time frame (e.g., the next day). 

Finally, according to MCG Health General Recovery Care 23rd Edition Wound and Skin Management GRG: PG-WS (ISC GRG), continued inpatient stay is needed until 1 or more of the following are present: Acceptable patient status for next level of care is achieved with ALL of the following present: Temperature status acceptable; No infection, or status acceptable; Pain and nausea absent or adequately managed. 

Thus, this patient could not have been treated in an ambulatory status with observation as the patient required diabetic management. In the setting of poorly controlled diabetes, the patient could have sustained an overwhelming infection. The patient therefore did require an acute care admission as the patient did have an acute medical condition in the form of an abscess in the setting of uncontrolled diabetes. 
The health care plan did not act reasonably, with sound medical judgment, and in the best interest of this patient in denying this inpatient admission, as the patient had uncontrolled diabetes in the setting of an abscess. 

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.