Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This is a patient with a history of hypertension, diabetes and rheumatoid arthritis. The patient presented to the Emergency Department (ED) for dizziness and abdominal pain. Glucose was 586. The patient was admitted for management of dizziness secondary to hyperglycemia. She was afebrile and hemodynamically stable. White blood cell count was 8.5, Platelets 226, blood glucose 586, Blood urea nitrogen (BUN)-to-creatinine ratio (BUN/Cr) 29.3/1.04, Sodium 128, Potassium 5.1, chloride 94, albumin/globulin (A/G) 9, Lactate 1.91, lipase 73, venous blood gas (VBG) potential hydrogen (PH) 7.34, Bicarbonate 24.8. Computed tomography (CT) of the head was negative for acute intracranial process. CT of abdomen with contrast showed moderate diffuse constipation. No bowel obstruction, ventral or inguinal hernia was noted. The patient received Lispro 8-units (U), Lactated Ringers one (1) liter (L) meclizine 25 milligrams (mg), and Reglan 10mg intravenous (IV) stat. She was continued on Meclizine for dizziness. Medications for uncontrolled hyperglycemia were started. Glycated hemoglobin (A1C) results were 14.2. She was started on basal insulin as well. Diabetic teaching provided on discharge since she is insulin naive. Once stable and blood sugar was controlled, the patient was discharged to follow up with the primary care provider.

Per notes, the patient presented to the hospital with dizziness and abdominal pain. The patient was noted to have an altered mental status (confusion) and was admitted due to high glucose at 586. With a blood glucose this high, inpatient intervention(s) were needed to stabilize the patient. She had a history of diabetes but had only been prescribed oral agents to control her condition, prior to admission. Although the patient was not in diabetic ketoacidosis (DKA), the patient had altered mental status with an A1c greater than 14%, indicating poorly controlled diabetes. This patient required intravenous (IV) fluids and insulin before she could safely be discharged, as her oral medication was not adequately treating her condition. Untreated diabetes can lead serious health complications including but not limited to heart attack, stroke and death. Given the patient's presenting condition, as well as medical history, it was necessary to be admitted.
 
"Glycated hemoglobin A1c levels are not altered by the onset of critical illness. Glycated hemoglobin A1c quantified at ICU admission can, therefore, be used to reliably estimate chronic glycemic control and guide acute glycemic therapy." (Luethi et al., 2016)

"In the hospital, both hyperglycemia and hypoglycemia are associated with adverse outcomes, including death (1,2). Therefore, inpatient goals should include the prevention of both hyperglycemia and hypoglycemia. Hospitals should promote the shortest safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission." (American Diabetes Association, 2018) 

""Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018).                                                         

Based on the above, the insurer's denial must be overturned. 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 full hospital admission is substantiated.