Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemia.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This is a male patient with a history of paranoid schizophrenia, depression, and high blood pressure. He presented to the Emergency Room (ER) with complaints of blurry vision and polyuria for the past week. His blood glucose level was greater than 600 for which 10 units of Novolog and intravenous (IV) fluids were given. The patient had uncontrolled newly diagnosed diabetes. He was admitted to the Medicine unit for hyperglycemia. Endocrinology service was consulted, and they recommended increasing Levemir dosage to 24 units at night and continuing with 10 units of aspartate three times a day. The care plan was implemented and the patient was discharged in hemodynamically stable condition. 

As per Pasquel and Umpierrez (2014), hyperosmolar hyperglycemic syndrome (HHS) is a clinical condition that arises from a complication of diabetes mellitus. This problem is most commonly seen in type 2 diabetes. Won Frerichs and Dreschfeld first described the disorder around 1880. They described patients with diabetes mellitus with profound hyperglycemia and glycosuria without the classic Kussmaul breathing or acetone in the urine seen in diabetic ketoacidosis. This clinical condition was formerly called non-ketotic hyperglycemic coma; hyperosmolar hyperglycemic non-ketotic syndrome, and hyperosmolar non-ketotic coma (HONK). HHS is a serious and potentially fatal complication of type 2 diabetes. As per Adeyinka and Kondamudi (2020), the mortality rate in HHS can be as high as 20% which is about 10 times higher than the mortality seen in diabetic ketoacidosis. Clinical outcome and prognosis in HHS are determined by several factors: age, the degree of dehydration, and the presence or lack of other comorbidities. Current diagnostic HHS criteria include a plasma glucose level >600 and increased effective plasma osmolality >320 in the absence of ketoacidosis. The incidence of HHS is estimated to be <1% of hospital admissions of patients with diabetes. The reported mortality is between 10 and 20%, which is about 10 times higher than the mortality rate in patients with diabetic ketoacidosis (DKA). As per Fayfman et al. (2017), "[e]arly diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events."

Based on the review of the medical record and literature, the inpatient hospital admission was medically necessary for this patient. This patient presented with uncontrolled newly diagnosed diabetes mellitus. The patient's blood sugar level was over 900 and was considered to be in a severe hyperglycemic emergency state, known as hyperosmolar nonketotic state (HONK). Literature supports that patients with HONK have larger fluid deficits which are masked and not initially seen until the patients' sugars improve. These patients are also prone to seizures due to fluid shifts and thus, carry a higher risk for mortality and/or other complications. Thus, this patient needed inpatient level of care for stabilization, close-monitoring and diabetic education.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
The medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.