Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Sugar (hyperglycemia)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is a young male followed by his pediatric endocrinologist for type 1 diabetes mellitus. He was diagnosed several months ago when he presented with polyuria, polydipsia, enuresis, and weight loss. The patient's hemoglobin A1c (glycated hemoglobin) was 11.5% (percent).  He needed aggressive intravenous (IV) fluid resuscitation and was started on insulin therapy using multiple daily injections. He needed maintenance intravenous fluids by report, and had labile blood glucose and 
multiple episodes of hypoglycemia. Coverage for the patient's inpatient diabetes education was denied by the health plan as not medically necessary, citing normal blood pressure and heart rate; normal mental state; dehydration was corrected quickly with fluids; no electrolyte issues; blood glucose was stable with insulin; tolerated oral fluids; no infection. The appeal letter from the patient's treating physician reports that the patient did meet MCG (Milliman Care guidelines) guidelines for inpatient admission: Diabetes, Pediatric ORG:P-140, and pointed out that his insulin regimen did need to be titrated due to several episodes of hypoglycemia.

The inpatient admission was medically necessary.

The setting for initial diabetes education in patients with new onset diabetes mellitus (inpatient versus outpatient) is practice-dependent. However, this patient is also quite young, presumably insulin-sensitive, and therefore needs close monitoring while his insulin doses are being titrated to avoid dangerously low blood sugars. Indeed, the patient did develop episodes of hypoglycemia that required treatment. Furthermore, survival skills education during hospitalization is needed for safe transition to community resources for continued and expanded diabetes self-management education. Acknowledging the challenges of teaching diabetes self-management in the hospital setting, the American Diabetes Association suggests that teaching diabetes "survival skills" is a reasonable approach to provide sufficient information and training to enable a safe transition to home (1,2). All young people with type 1 diabetes and their caregivers deserve quality care, with structured diabetes education from a diabetes team or health care professional experienced in pediatric diabetes. The initial focus should be on the acquisition of the practical "survival skills" required to manage the diabetes at home and address the immediate concerns expressed by the family. Time should be given for the skills to be practiced and basic concepts should be reviewed within the first weeks of diagnosis. The family should be given a structured plan for education so that they can arrange dedicated time for the education. At diagnosis, concepts are new, and the child or adolescent will need consistent messages and support from parents and other primary care givers. To ensure this occurs, both parents or other primary care givers, should be encouraged to attend all education sessions (3). Due to the heterogeneity of health care systems and funding of diabetes care and education, there is evidence supporting both inpatient and ambulatory approaches to diabetes stabilization and initial education at diagnosis (4-10). However, in this case, the patient is quite young and therefore needed the close monitoring to ensure dangerous lows are treated when they occur as the diabetes team is figuring out his insulin needs. Therefore, the inpatient admission was medically necessary.