Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregestational Diabetes.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a gravida (G) 2 para (P) 1 who was at 33-6/7 weeks gestational age. The patient had a prior history of a 40 week term vaginal delivery of 3629 grams (g) or 8 pounds. The patient's blood glucose at  was 118 and then was 191. The patient was admitted to the hospital for expedited glycemic control given likely undiagnosed pre-gestational diabetes based on a hemoglobin A1c of 7% at her first prenatal visit. The patient's history was also complicated by a likely large for gestational age infant. She  also had a history of obesity and of advanced maternal age. On ultrasound, the infant was vertex with an anterior placenta and polyhydramnios of 23 centimeters (cm) with estimated fetal weight of 3738 g or the 97th percentile with the abdominal circumference also at the 97th percentile. A fingerstick blood glucose had been reported as 218 at the outlying clinic. The patient was to start on a weight based insulin regimen and nutrition consult and diabetic teaching was ordered. The patient was also to be scheduled for a fetal echocardiogram (echo) post discharge and would benefit from weekly fetal testing as well as ongoing testing (nonstress test, biophysical profile, growth ultrasound) in this pregnancy. A plan was made for possible delivery at 37-38 weeks based on poor glycemic control. The patient was counseled on uncontrolled diabetes and pregnancy and long-term outcomes.

The patient denied any history of contractions, vaginal bleeding or leakage of fluid. She reported good fetal movement. Her medications included prenatal vitamins and metformin 500 milligrams (mg) daily that she was intermittently taking. She reported no known allergies. She had no history of tobacco use, ethanol use, or drug use. The patient had a history of anxiety or depression. She had transferred at 33 weeks gestation to the United States. The patient's hematocrit was 31.1% with platelets of 198 and a white blood cell count 6.2. A hepatitis B test was nonreactive. Her blood type was A positive (+) with a negative antibody screen. Human immunodeficiency virus (HIV) and rapid plasma reagin (RPR) was nonreactive. Rubella and varicella were unknown. Fetal testing was noted to be reassuring with a baseline rate in the 150s with moderate variability and absent accelerations or decelerations. Uterine contractions were denied. Membranes were intact and cervical exam was deferred. The patient was planned for labs for baseline preeclampsia evaluation as well as a 24-hour protein.

During hospitalization, the patient was counseled on the use of a glucose meter as well as an insulin pen for administration of insulin. She was started on Levemir 25 units and 30 units at bedtime. The patient was also to take Humalog 12 units with meals. Patient's vital signs remained stable and fetal testing was reassuring. Labs noted a normal basic metabolic count and normal liver function tests. Her hemoglobin A1c was 9.7% glucose was 147 and assessment. The patient was counseled on monitoring of her blood glucose and had a formal diabetic counseling session while in the hospital. She was also seen and counseled by maternal fetal medicine with a plan up twice per week testing in the outpatient setting. The patient was noted to have no acute events overnight and continued to have stable vital signs. The patient's examination was benign, and fetal testing was reassuring. She had a negative swab for coronavirus. The patient declined an influenza vaccination. She was discharged home with follow-up in the outpatient setting. During the hospitalization, comprehensive nutritional evaluation and counseling took place as well as diabetic counseling. The patient was also counseled her plan of care given undiagnosed type 2 diabetes. The patient was scheduled for follow-up in the outpatient setting for twice per week fetal testing as well as likely delivery at 37-38 weeks. She was counseled on dietary planning during her pregnancy and with the diagnosis of diabetes. At issue is the medical necessity of an inpatient stay.

Based upon a review of the medical records outlining the inpatient hospital stay and a review of the Milliman Care Guidelines (MCG) "Diabetes in Pregnancy" guidelines and American College of Obstetricians and Gynecologists (ACOG) recommendations, an acute inpatient admission was not medically necessary for this patient with a new diagnosis of diabetes in pregnancy. In this case, the patient was noted at that time to have class II obesity and diabetes. The patient was admitted to the hospital for evaluation and management with diabetic teaching. She was also noted to have formal endocrine teaching and insulin training. The patient was also seen by endocrine and maternal fetal medicine who set up a plan of insulin management for this patient. Fetal testing was reassuring during hospitalization without any concern for non-reassuring fetal well-being. The MCG "Diabetes in Pregnancy" guideline outlines the following indications for admission to acute inpatient care in this setting:
"** Diabetes is uncontrolled or needs urgent intervention as indicated by 1 or more of the following:  1) Ketoacidosis - this was not present as this was Type II Diabetes, 2) Hyperglycemia associated with volume depletion - this was not demonstrated based upon a normal UA and normal vital signs, 3) 	Hypoglycemia not readily reversed by outpatient or emergency department care - this was not noted as there was no trial of outpatient management, 4) Persistent hyperglycemia unresponsive to outpatient intervention - this was not present as the patient had no trial of outpatient management for her diabetes, 5) Rapid initiation of metabolic control needed to improve maternal and fetal outcome - both maternal and fetal status were stable and reassuring throughout admission and rapid initiation was not necessary in this case, 6) Vomiting not controlled by outpatient therapy - there was no trial of outpatient therapy and no documentation of recalcitrant vomiting.
**Management at other levels of care (see Diabetes: Observation Care ISC guideline as appropriate) is not feasible because of 1 or more of the following:
Condition was not adequately corrected with treatment at other levels of care. - there was no trial of therapy at other levels of care.
-	Treatment at other levels of care is not appropriate because of condition severity (eg,hyperosmolar coma).- this was not present as the patient and fetus were stable."

Thus, based upon a review of the MCG Guideline, there was no indication for admission to acute inpatient therapy in this case.

In this case, the patient had a diagnosis of pregestational, Type II Diabetes that was poorly controlled due to a lack of recognition of diagnosis and pregnancy. ACOG recognizes the standard of care for treatment in this condition in their practice bulletin entitled "Pregestational Diabetes Mellitus". Pregnancy is characterized by increased insulin resistance and reduced sensitivity to insulin action. Late in the first trimester, relatively higher levels of estrogen enhance insulin sensitivity and, when associated with nausea and vomiting, increase the risk for maternal hypoglycemia. The increase in insulin resistance is largely the result of a mixture of placental hormones, including human placental lactogen, progesterone, prolactin, placental growth hormone, and cortisol. The management of diabetes in pregnancy must focus on excellent glucose control achieved using a careful combination of diet, exercise, and insulin therapy. Patients may need to be seen every 1-2 weeks during the first two trimesters and weekly after 28-30 weeks of gestation. During pregnancy, caloric requirements are increased approximately 300 kilocalories (kcal) higher than basal needs in patients with a singleton fetus which was recommended by the dietician. Carbohydrate counting increases dietary flexibility and is extremely useful as long as the total daily caloric intake is considered to avoid excessive weight gain. A registered dietitian may be of value in providing an individualized nutrition program. On average, insulin needs increase from a range of 0.7-0.8 units per kilogram per day (U/kg/d) in the first trimester, to 0.8-1 U/kg/d in the second trimester, to 0.9-1.2 U/kg/d in the third trimester. Usually, a rapid acting insulin is combined with Neutral Protamine Hagedorn (NPH) in control of diabetes. This calculation allows for dosing of this insulin. Frequent visits are made when starting insulin. Blood glucose levels would be monitored fasting and 1-2 hours postprandial for management and insulin adjustment. In this case, the insulin would be calculated with outpatient dietician consultation and started with 2-3 times per week follow-up for adjusting insulin. Testing of the fetus could be by nonstress test (NST) or biophysical profile (BPP) in the office at these visits. Consultation with maternal fetal medicine and endocrine can also be completed as an outpatient.