Appeal type: Medical necessity
Decision: Upheld

Diagnosis Abdominal Pain 
Treatment: Inpatient stay. 

The insurer denied an inpatient stay. The determination is upheld. 

The patient presented to the hospital with epigastric pain radiating to the back and lower abdomen in addition to a bilateral buttock ulcer that started as a blister and ruptured releasing pus/blood. 

On presentation, she was afebrile with blood pressure 118/75, heart rate 83, respiratory rate 16, and with an oxygen saturation of 95% on room air. The exam otherwise noted epigastric and suprapubic tenderness. Labs resulted with a white blood cell count (WBC)of 7.0, hemoglobin (HGB) 13.2, platelets 326, sodium 123, potassium 4.2, blood urea nitrogen (BUN) 16.5, creatinine 1.87, bicarbonate 25, glucose 740, serum ketones negative, lipase 218 (normal less than [<] 78) with the rest of her liver function tests within normal limits, and venous blood gas with potential of hydrogen (pH) 7.317/ partial pressure of carbon dioxide (pCO2) 49. A urinalysis did not show evidence of an acute infection. An electrocardiogram (EKG) showed normal sinus rhythm with T wave inversions in multiple leads and prolonged QT. A chest x-ray showed no acute process. Wound cultures of her furuncles were obtained. The patient was brought into the hospital with concerns for acute pancreatitis, uncontrolled diabetes with hyperglycemia and without concerns for acidosis, acute kidney injury, and furuncle of the buttock, and plans for intravenous (IV) fluids, glucose control with subcutaneous insulin, unasyn, laboratory monitoring, and pain and nausea control. 

She was hemodynamically stable without a fever, hypotension, tachycardia, tachypnea, or hypoxia. The patient denied abdominal pain, nausea, or vomiting, and was tolerating food without difficulties. The exam noted gluteal fold bilateral small furuncles. Repeat labs noted a complete blood count (CBC) that was unremarkable, sodium of 131, potassium 3.6, BUN 10.7, creatinine 1.31, glucoses of 348-500, and anion gap of 10. Hemoglobin (HGB) A1c resulted at 14. The plan was to continue IV fluids and subcutaneous insulin in addition to unasyn and wet to dry dressings of her buttock wounds. 

She continued to have hyperglycemia into the 300s. The recommendation was that she stay for ongoing treatment of her uncontrolled hyperglycemia and skin infection with furuncles, but the patient ultimately decided to leave against medical advice. 
At issue is whether care at the inpatient level of care was medically necessary.
1. Did the health plan, in its determination of medical necessity, act reasonably, with sound medical judgment and in the best interest of the patient? The requested health service of inpatient stay was not medically necessary. This is a patient with uncontrolled diabetes mellitus and hemoglobin A1c of 14% who presented with epigastric pain concerning for pancreatitis in addition to furuncles of the buttocks. On presentation, she was afebrile with normotension, without tachycardia or tachypnea, with a WBC that was normal, uncontrolled hyperglycemia with pseudohyponatremia and with furuncles noted on exam without evidence of deeper infection. She was appropriate for care with IV fluids, treatment of hyperglycemia, and monitoring of abdominal pain, ability to tolerate oral intake, and monitoring to ensure her furuncles did not develop into a more serious infection. It is noted, however, that by the second day of hospitalization, she was able to tolerate oral intake without abdominal pain and stable to discharge from a pancreatitis perspective. The primary issue for remaining in the hospital was ongoing monitoring of her blood glucose and basic metabolic panel. She continued to have no leukocytosis or other signs of systemic infection associated with her furuncles, or evidence of developing frank cellulitis, and plan of care was antibiotics, glucose management, and wet to dry dressings. It is unclear why in the absence of deep infection (frank carbuncle or cellulitis), systemic signs of infection (no leukocytosis, hypotension, fever), with hyperglycemia being the primary issue for remaining in the hospital why she required ongoing hospital care and could not have been safely managed at a lower level of care. 

In the absence of severe pancreatitis requiring inpatient management (with this patient able to eat and stable for discharge the day after presentation from this perspective), and with hyperglycemia that was not associated with diabetic ketoacidosis or hyperosmolar coma, and with only mild acute kidney injury and superficial furuncle infection with no signs of systemic inflammation, an inpatient stay was not medically necessary.