Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient has a history of asthma and presented for an emergency evaluation due to feeling weak and dizzy for two days as well as vomiting. On initial presentation, the patient was afebrile (temperature of 98.1 degrees Fahrenheit), tachycardia to a heart rate of 106, with normal blood pressure 120/84.

Laboratory studies were remarkable for hyperglycemia with glucose 602, elevated hemoglobin at 15.8, hyponatremia with sodium 133, elevated alkaline phosphatase at 143, glucosuria >(greater than) 1000 milligrams/deciliter (mg/dL), and ketonuria. Electrocardiogram (EKG) demonstrated sinus tachycardia with a heart rate of 106. 

In the emergency department, the patient was administered two liters of normal saline intravenous (IV) fluids, Zofran, and famotidine. Upon serial monitoring, the patient had ongoing hyperglycemia to glucose 497 followed by 416, consistent with failure to achieve symptom improvement and further supporting the necessity of acute inpatient care. Bicarbonate (HCO3) was normal at 24. Anion gap was normal. 

The patient required acute inpatient care for the management of hyperglycemia and tachycardia.

Treatment plan consisted of serial glucose monitoring, normal saline IV fluids at 200 milliliters/hours (ml/hr), glargine 8 units nightly, insulin lispro sliding scale coverage, evaluation of gad65, hemoglobin a1c, and lipids. The patient was found to have a hemoglobin A1C of 15.5. The patient was dehydrated and had vomiting. The patient was discharged after clinical stabilization. 

The patient could not have been discharged home safely from the emergency room (ER). The admission was medically necessary.

The inpatient admission for this patient is medically necessary.

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 (US) (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."  That is not the case for type 2 diabetes. Indications for admission for new onset type 2 diabetes are more stringent and dependent upon the presence of symptoms such as ketosis, dehydration, hyperosmolarity, vomiting and inability to maintain hydration or severe metabolic/electrolyte abnormalities.  

There are no randomized controlled trials comparing inpatient to outpatient diabetes education in type 2 diabetes. Arguably, a patient with polyuria, polydipsia, dehydration, vomiting,  ketosis and a glucose in the 600s ought to receive rehydration and insulin therapy to achieve the fastest and best control of the patient's diabetes (5-8) as well as new onset diabetes education. The admission was 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 the inpatient is substantiated.