Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male on the autism spectrum with echolalia and behavior concerns (on Abilify 5mg twice daily [BID]) who was sent to the emergency room (ER) from his primary care physician's (PCP) office after urinalysis (UA) there showed glucosuria (500) and ketonuria (greater than [>]160). He was at the PCP for a well child check and the PCP decided to check a UA due to mother's reporting of polyuria and polydipsia. Mother reports that he always drinks a lot of fluids but recently he has been having increased thirst. He drinks eight 32 oz. cups of fluid daily. He has lost 5 lbs. unintentionally over the last 6 months to 1 year. He had previously lost a significant amount of weight intentionally due to diet modifications for overweight. Mother reports that he eats a lot and constantly grazes around the house. Mother denies any recent illness but has noticed that he was sluggish over the last week. No fevers, upper respiratory infection (URI) symptoms, nausea, vomiting or diarrhea. No travel, sick contacts or COVID contacts.

In the ER he was noted to have blood pressure (BP) of 102/73, heart rate (HR) 99, temperature (T) 98.3, respiratory rate (RR) 23, and oxygen (O2) saturation of 96% on room air (RA). Physical exam was pertinent for acanthosis nigricans. Lab values revealed initial glucose 228, venous blood gas (VBG) with potential hydrogen (pH) 7.37, Bicarb 21, UA glucose >1000, protein 30. Glycated hemoglobin (Hgb A1C) >14%. He was given a normal saline (NS) bolus of 10 milliliters per kilogram (mL/kg) and started on intravenous fluids (IVF) at 100 milliliter (mL) per hour. He was given 18 units (U) of Lantus and 4U of Lispro. Consult was placed for Pediatric Endocrinology.
Assessment by admitting physician reports patient's labs not consistent with diabetic ketoacidosis (DKA). Decision was made to admit to the pediatric endocrinology service for initiation of insulin regimen and diabetes education.  Plan upon admission was for repeat glucose 2-3 hr. after insulin, repeat labs in AM and finger stick glucose levels before meals. IVF were discontinued and the patient was started on a diabetic diet with rapid insulin regimen and plan for follow-up (f/u) with endocrinology for diabetes education in the AM.The patient and his family received education with the diabetes educator and was cleared for discharge by the primary Pediatric Endocrinology service with close follow up. Due to his underlying condition and family unable to work out ratios he was discharged on an insulin sliding scale. He was sent home with a blood glucose meter and supplies as well as urine test strips and his insulin. The subject under review is the medical necessity for the inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. He was not in DKA nor did he have any signs of clinical instability evidenced by stable vital signs as well as no vomiting, diarrhea or altered mental status. He was able to tolerate by mouth (PO) intake at the outset. He did not require continuous IV insulin drip. He was immediately started on a diabetic diet and subcutaneous insulin with good result. For these reasons, inpatient level of care would not have been medically necessary for this patient.