Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a medical history of intermittent asthma, obesity, and type I diabetes mellitus that presented to the emergency department (ED) with abdominal pain, decreased appetite, weakness, and hyperglycemia. He had been visiting his sibling and his mother was not sure if he was receiving all of his prescribed insulin. When he returned home the day prior to presentation, his blood sugar was in the 500s. His mother administered correctional insulin followed by his long-acting insulin at bedtime. Subsequently, he was refusing to eat and drink except for Pedialyte. The morning of admission, he was experiencing abdominal pain and nausea with one episode of vomiting. His blood sugar at that time was 383 and was treated with correction. He only voided twice throughout the day. He had no fevers or cold symptoms. Historically, he had been admitted three times for diabetic ketoacidosis (DKA) in the past. The blood glucose on arrival was 151. No infectious source was identified. The prevailing concern was that the child was non-compliant. He was treated with a normal saline bolus. The blood sugar following that first bolus was 137. He was treated with a second bolus. Pediatric endocrinology was contacted with recommendations to continue his home regimen for glycemic control. Admission orders included a pediatric diet with medium consistent carbohydrate diet, maintenance intravenous (IV) fluids, monitor blood glucose seven times daily, hypoglycemia protocol, and insulin per Endocrinology recommendations.
He did well overnight. He was tolerating his diet and insulin administration. Outpatient appointments were recommended. He was cleared for discharge after social services consultation. The blood sugars varied from 150-231, and were corrected as needed with no changes to his usual regimen. He was cleared by social services and discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The inpatient stay is not medically necessary.
Diabetes mellitus is a chronic metabolic disease characterized by hyperglycemia. There are three basic types, gestational diabetes, type I diabetes, and type II diabetes. In type I diabetes, insulin secretion is deficient as a result of damage to pancreatic islet cells. Type II diabetes occurs when tissues in the body develop insulin resistance. Gestational diabetes occurs with pregnancy. Type I diabetes is the most common metabolic disorder of childhood and adolescence, with peak incidence at 5-7 years of age, and at the time of puberty. Males and females are equally affected, except in low risk populations where there is a slight increase in females. A number of genes have been identified in type I diabetes, and environmental factors also play a role. Insulin is essential for storage and utilization of cellular fuel. In the normal state, insulin levels increase and decrease corresponding to intake of food. Without insulin, tissues cannot use nutrient fuel. Hyperglycemia and catabolism result, with the breakdown of fats and formation of ketone bodies, with accumulation of ketoacids. The clinical presentation is governed by degree of hyperglycemia and development of ketoacidosis. Hyperglycemia produces an osmotic diuresis, with progressive dehydration. Accumulation of ketoacids results in development of metabolic acidosis. Complications of uncontrolled hyperglycemia include diabetic ketoacidosis (DKA) with risk of cerebral edema, and nonketotic hyperosmolar coma. Management of type I diabetes involves administration of exogenous insulin, either by intermittent subcutaneous injections or insulin pump therapy, as well as glucose monitoring and lifestyle changes. Noncompliance with therapy as well as infections and other stressors can adversely affect glycemic control, with development of hyperglycemia and eventual DKA.
According to clinical care guidelines for pediatric diabetes, admission is indicated by at least one of the following: uncontrolled diabetes with diabetic ketoacidosis (glucose greater than 250, bicarbonate less than 15, moderate ketonuria), hyperglycemic hyperosmolar state (altered mental status, glucose greater than 600, serum osmolality greater than 320), severe signs or symptoms secondary to hyperglycemia (altered mental status, significant dehydration, intractable vomiting, unexplained fever or severe infection, severe electrolyte abnormalities), and neurologic deficit. The expected length of stay according to the guidelines is one day. Extension may be indicated for treatment for a precipitating cause such as infection, persistent metabolic derangements such as acidosis, coma or mental status change, and cerebral edema.
This male child with a medical history significant for atopic disease and type I diabetes presented to the ED with hyperglycemia and abdominal pain. His serum carbon dioxide (CO2) was 12 and he had urine ketones, but the venous potential hydrogen (pH) was 7.34. He did not present with diabetic ketoacidosis, rather hyperglycemia with associated abdominal pain, likely secondary to non-compliance. While it was reasonable to monitor this child in the hospital for resolution of hyperglycemia and additional diabetes teaching, he was overall hemodynamically stable with no abnormalities in his respirations, no evidence of severe complications (eg cerebral edema), and no significant dehydration. He did not require acute inpatient admission and could have been managed at a lower level of care.