Appeal type: Medical necessity
Decision: Upheld

Gestational Diabetes
Inpatient Hospital

The patient is a pregnant female who presented at 19 weeks and 6 days gestation with concern for headache. The patient was noted to be dated by last posterior, consistent with 8 week ultrasound and was transported from an outside hospital for intractable headache. The patient reported that her headache started with frontal throbbing and neck stiffness with photophobia. The patient tried Tylenol without relief and had vomiting on 4 occasions. She was evaluated at the outside hospital and had a negative computed tomography (CT) scan of the head and normal labs. Her headache remained despite Benadryl, morphine, magnesium, Reglan, Vistaril and Nubain. The patient reported that her symptoms were unchanged at presentation. She denies any vertigo, chest pain, shortness of breath, nausea, vomiting, vaginal bleeding, leakage of fluid, or contractions. She endorsed positive fetal movement. The patient was admitted to the hospital. The inpatient stay is under review. 

The health plan's determination is upheld. The inpatient stay is not medically necessary. In this case, the patient is noted to have a diagnosis of pregestational, Type I Diabetes that was poorly controlled due to pregnancy. The American Congress of ObGyn 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 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 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 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 followup for adjusting insulin. Testing of the fetus could be by NST or BPP in the office at these visits. Consultation with neurology and endocrine can also be completed as an outpatient.
Based upon a review of the MCG Guidelines, there would be no indication for admission to the acute inpatient level of care in this case. In this case, the patient could have been cared for at a lower level of care.