Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Blood Sugar Level
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is a toddler aged male, previously well, admitted for recurrent hypoglycemia in the setting of persistent vomiting. He initially presented at the emergency department (ED) with 4 days of persistent vomiting and abdominal pains. The patient was noted to have hypoglycemia at 48 mg/dl (milligrams per deciliter). He was febrile the previous day to 101 degrees Fahrenheit. He was given intravenous (IV) fluids, juice. Blood glucose rose to 62 mg/dl (milligrams per deciliter), and he was given more juice and IV (intravenous) dextrose. Abdominal X-ray showed mild distention. Abdominal ultrasound showed no intussusception, while appendix could not be visualized. The patient was discharged after passing PO (oral) challenge. Four days later, he was taken to the ED (emergency department) again, as he continued to have emesis at home up to five times, with no bowel movement for four days. He could not tolerate PO (oral) intake except for a few crackers. He continued to have abdominal pains as well. The patient's pulse rate (PR) was 139, glucose low at 44 mg/dl (milligrams per deciliter), AST (aspartate aminotransferase) was elevated at 73. Abdominal ultrasound showed mesenteric adenitis. He was given IV (intravenous) dextrose bolus which improved blood glucose to 124. However, this dropped again to 59 mg/dL (milligrams per deciliter) two hours later, despite IV (intravenous) dextrose infusion. Pediatric endocrine was consulted for recurrent hypoglycemia who recommended admission. He was admitted due to a "new requirement of parenteral nutrition, requirement for frequent monitoring vital sign and blood sugars." 

Yes, the Inpatient Hospital Admission was medically necessary. 

Hypoglycemic disorders are rare, but their consequences, particularly for children, can be severe and disabling. Hypoglycemia may result in seizures and brain damage, which lead to developmental delays, physical and learning disabilities, and, in rare cases, death (1, 2). This is one of the concerns in patients with refractory hypoglycemia, and one of the main reasons for inpatient admission, particularly if standard measures for treating hypoglycemia have been inadequate to maintain normoglycemia. Given these severe consequences, the prompt diagnosis and appropriate management of hypoglycemic disorders in children are crucial. Although this patient was eventually diagnosed with benign ketotic hypoglycemia, this is a diagnosis of exclusion and could only be arrived at after a more thorough evaluation has been completed inpatient. 

This patient presented with severe recurrent hypoglycemia that persisted for several days. At the second ED (emergency department) visit, the patient presented with blood glucose of 44 mg/dL (milligrams per deciliter), which initially improved with treatment, but dropped again despite IV (intravenous) dextrose, prompting admission inpatient. Initial laboratory investigation for causes of hypoglycemia was inconclusive as blood glucose in the "critical sample" did not meet criteria for hypoglycemia (cut off less than 50 mg/dl [milligrams per deciliter]). Goals of inpatient admission in this case is two-pronged a) to treat hypoglycemia with continuous IV (intravenous)dextrose infusion as well as close observation for severe symptoms of hypoglycemia (e.g., seizures), and b) to obtain "critical sample" if serial blood glucose monitoring meets criteria for hypoglycemia ("critical sample", less than 50 mg/dL [milligrams per deciliter]) despite measures to prevent hypoglycemia (which would indicate a more serious cause of hypoglycemia than benign ketotic hypoglycemia from prolonged fasting secondary to illness). These measures cannot be conducted outpatient. Hence, 
inpatient admission was medically necessary.