Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital stay. 
The denial was upheld in whole. 

The patient is a  gravida (G)3 para (P)1 abortion (Ab) 1 who presented to the hospital with for diabetic control. The patient had been taking insulin prior to admission but was not sure of the dose she was taking. She admitted to dietary indiscretion in the form of excessive carbohydrate intake including concentrated carbohydrates. The patient had not completed a consultation with dietitian at the time of admission. She also had increased blood pressure over two years prior history not on medication. The patient's prior pregnancy history was noted for a 6 week spontaneous miscarriage requiring dilation and curettage. She also underwent an elective Cesarean delivery at 38 weeks gestation which resulted in a 7-1/2 pound female infant. The patient's prior history was noted for a left breast biopsy and left breast cyst removal. There is a family history of diabetes in her father and hypertension in her mother. She denied use of alcohol, tobacco or illicit substances.

At the time of admission, the patient was at 32 weeks gestation. She was admitted for control of diabetes as well as stabilization of fetal size and amniotic fluid excess. She was being monitored on labor and delivery. The patient's home medications are documented as an aspirin per day, Pepcid, and insulin 25 units of NPH taken every evening. The patient underwent lab testing which noted a normal hemoglobin of 11.9 with hematocrit 37.2 and platelets were normal at 281. A complete metabolic profile was also normal. The patient had a normal blood pressure 127/78 with a heart rate of 100. She was afebrile at 98.2 Fahrenheit (F). Her respiratory rate was normal at 20. Her examination was benign and there were no abnormalities noted. Point-of-care glucose was performed throughout her hospitalization and the patient was also started on Lantus and Humalog regimen. She also received pneumococcal vaccine as well as influenza vaccine as these were reviewed and had not been completed in this pregnancy. During this hospitalization, the patient was prescribed a regimen of Lantus insulin 10 units at 10 AM and Lispro insulin 3 units prior to meals. Urinary protein/creatinine ratio was normal. The patient was counseled on her monitoring plan for diabetes and dietary planning. She had normal blood pressure and reassuring status by vitals and fetal assessment throughout the time in the hospital.

The health plan's determination is upheld in whole.

The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient given the diagnosis of poorly controlled diabetes in pregnancy. Consultation with dietary and endocrine can be completed at a lower level of care status. Monitoring and care for diabetes can be completed at a lower level of care status. In this case, there was no report of fetal non reassuring status. Fetal testing was reassuring. Based upon these records and the American College of Obstetrics and Gynecology, the care could be provided at a lower level of care and would not require admission to acute inpatient level of care in this case.