Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Increased blood sugars
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history significant for mild intermittent asthma and type 2 diabetes who presented to the emergency department (ED) with a two-day history of increased blood sugars 300s-400s, dizziness, fatigue, blurry vision, and feeling "cold". She was seen in a different ED the previous day, was treated with intravenous (IV) fluids, and discharged home with blood sugars in the 200s. The maximum blood sugar on this day was 370. Historically, she had been treated with insulin but was currently on metformin. The patient's examination was significant for low energy, lying on a cot, moist mucous membranes, benign abdomen, and non-focal neurologic exam. 
She was started on maintenance intravenous (IV) fluids and pediatric endocrinology was contacted. Recommendations included normal saline IV fluids at maintenance, 16 units (U) Lantus, and admission for initiation of insulin and diabetes education. She received diabetes education, nutritional support, and psychological support throughout her hospital stay and was deemed stable for discharge. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. Diabetes mellitus is a chronic metabolic disease characterized by hyperglycemia. There are three basic types, gestational diabetes, type I diabetes, and type II diabetes. In type I diabetes, insulin secretion is deficient as a result of damage to pancreatic islet cells. Type II diabetes occurs when tissues in the body develop insulin resistance. Gestational diabetes occurs with pregnancy. Type I diabetes is the most common metabolic disorder of childhood and adolescence, with peak incidence at 5-7 years of age, and at the time of puberty. Males and females are equally affected, except in low risk populations where there is a slight increase in females. A number of genes have been identified in type I diabetes, and environmental factors also play a role. Insulin is essential for storage and utilization of cellular fuel. In the normal state, insulin levels increase and decrease corresponding to intake of food. Without insulin, tissues cannot use nutrient fuel. Hyperglycemia and catabolism result, with breakdown of fats and formation of ketone bodies, with accumulation of ketoacids. Clinical presentation is governed by degree of hyperglycemia and development of ketoacidosis. Hyperglycemia produces an osmotic diuresis, with progressive dehydration. Accumulation of ketoacids results in development of metabolic acidosis. Complications of uncontrolled hyperglycemia include diabetic ketoacidosis (DKA) with a risk of cerebral edema, and nonketotic hyperosmolar coma. Management of type I diabetes involves administration of exogenous insulin, either by intermittent subcutaneous injections or insulin pump therapy, as well as glucose monitoring and lifestyle changes. Noncompliance with therapy as well as infections and other stressors can adversely affect glycemic control, with development of hyperglycemia and eventual diabetic ketoacidosis (DKA).
This patient with a history of type 2 diabetes and asthma presented with persistently elevated blood sugars despite oral hypoglycemic. She was started on insulin therapy and provided comprehensive diabetes education. She did not present in DKA as would be expected with type 1 diabetes, but it was also not completely clear that she had type 2 diabetes. Further laboratory investigation was conducted while she was hospitalized. She responded well to both medication and education and was stable for discharge. While it was reasonable and appropriate to monitor in the hospital while adjusting her medication management and providing essential education and support, she was overall hemodynamically stable with no evidence of DKA or other complications of diabetes, she was not profoundly dehydrated or in distress. She did not require acute inpatient admission and could have been safely managed at a lower level of care.