Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a female with a medical history significant for diabetes mellitus that presented to the emergency department (ED) with post-prandial hyperglycemia of 600. She was treated with 10 units of Humalog after which she felt dizzy and nauseous, with some chest tightness. She had been seen by her endocrinologist about a week prior to this episode. Her vital signs included temperature 36.7, heart rate 80, respiratory rate 20, and blood pressure 129/89. The examination was unremarkable. The laboratory evaluation included a urinalysis with 4 plus glucose. Her venous blood gas with bicarbonate 28.7, serum glucose 299, alkaline phosphatase 240.0, negative C-reactive protein (CRP), platelets 149, and her carbon dioxide (CO2) was 27. The bedside glucose upon arrival was 365. The electrocardiogram was unremarkable except for bradycardia with a heart rate of 58. She was treated with a Normal Saline bolus. Endocrinology was contacted with recommendations for admission for diabetes education in the context of hyperglycemia and poorly controlled diabetes. There was no evidence of diabetic ketoacidosis (DKA).
Admission orders included pediatric age-appropriate diet, Metformin, Lantus Insulin, Humalog Insulin based on carbohydrate counting, nutrition consultation, diabetes education, social evaluation and clearance, and bedside glucose checks before meals and at 0300 hours. The following day, she was prescribed Famotidine for stomach pain. She had no complaints, and she was eating well. Her blood sugars ranged 264-278. Then her blood sugars ranged 147-283. She was complaining of dizziness as well as blurry vision and abdominal pain as severe as 8 out of 10. She was referred to a cardiologist for evaluation of the dizziness and chest tightness. The abdominal pain was attributed to Metformin.

A social work consultation was completed at which time she was socially cleared for discharge home with her mother. Later that day she was found on the floor smiling twice. Continuous observation was ordered. Neurology was consulted because of refusal to walk and reports of numbness and dizziness. The cardiology consultation yielded a diagnosis of costochondritis, gastroesophageal reflux, or psychiatric issue with recommendation to obtain lipid panel. Multiple electrocardiograms were normal. She was cleared by psychiatry and prescribed Hydroxyzine every six hours as needed. The lipid panel and troponin were within normal limits. The following day, she again complained of dizziness, chest tightness, and abdominal pain. She refused to get out of bed and maintained that she could not go home. Her blood sugars were in the range of 100-200 and then 86-138. She had been cleared by all specialty consultants and was deemed stable for discharge.

An acute inpatient admission was medically necessary. This patient was admitted with hyperglycemia in the context of recently diagnosed diabetes. Laboratory testing was not consistent with DKA, but rather poorly controlled blood glucose and non-compliance with the recommended diet. Typically, such a situation could be handled in the outpatient setting or with a brief hospital stay. In this case, the patient complained of chest pain, dizziness, and abdominal pain. She was found on the ground multiple times after falling. She eventually refused to get out of bed and walk. Multiple consultations were sought with neurology, cardiology, and psychiatry. Diagnostic studies were negative, including electrocardiograms and laboratory studies. Much of her presentation was considered somatization. However, it was necessary to evaluate for possible organic causation prior to considering discharge. Once she had been cleared by the various consultants and her blood sugars were within acceptable range, she was discharged home.