Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

According to the medical records, the patient has a history of hypertension, insulin dependent diabetes mellitus and coronary artery disease with a history of three coronary stents. The patient arrived at the emergency room (ER) via ambulance, after a syncopal episode related to hypoglycemia. Physical examination of the patient demonstrated frontal scalp lacerations, left mandibular swelling and limited mobility when opening his mouth. The ER physician ordered labs and radiologic imaging, which showed a left mandibular fracture with a mildly deviated septum. He was treated with oral and intravenous glucose, intravenous fluids and analgesics. He was transferred to the telemetry unit and received continuous cardiac monitoring. The patient had an orthopedic consultation but refused surgery at that time. His hypoglycemia and clinical status improved, and he was discharged.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.      

"We built on existing literature identifying sulfonylurea and insulin use as important hypoglycemia risk factors 23-25,32 by examining these medications in parallel with other relevant risk factors, differentiating between basal insulin and basal plus bolus insulin regimens and exploring the implications of concurrent sulfonylurea and insulin use. In both unadjusted and adjusted analyses, patients treated with sulfonylurea, basal insulin, and basal plus bolus insulin regimens experienced incrementally increasing rates of hypoglycemia-related ER visits and hospitalizations. Specifically, in multivariable analysis, sulfonylurea use was associated with an almost 7-fold higher risk of a hypoglycemia-related visit or hospitalization, basal insulin use was associated with a 12.5-fold increase in risk, and basal plus bolus insulin use was associated with an almost 28-fold increase in risk. This increase in hypoglycemia risk is higher than previously described, 23-25,32 but those studies did not directly compare sulfonylurea, basal insulin, multiple daily insulin injections, and other glucose level-lowering drugs with each other and within the same diverse patient population in a real-world setting. We found that for patients with type 2 diabetes, it seems that the addition of sulfonylurea to insulin (whether basal only or basal plus bolus) did not increase the risk of hypoglycemia-related ER and hospital care beyond what was observed for insulin alone." (McCoy et al).                                                         

"Time to treatment after identification was faster when identified by care testing versus serum sample result... About one-third of patients had refractory or recurrent hypoglycemia and infection was associated with this occurrence. Lack of dextrose containing intravenous fluid was associated with the incidence of recurrent hypoglycemia." (Bilhimer et al).

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.