Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld. 

This female patient has a history of congestive heart failure, type 1 diabetes mellitus, and depression. The patient presented to the Emergency Department (ED) with complaints of urinary frequency and hyperglycemia. She reported she had been urinating every 2 hours and noticing worsening peripheral edema. The patient also reported severe depression for the prior couple of months due to family reasons. She reported lack of emotional support at home, personal care, and non-compliance with her insulin medication. The patient's physical exam was remarkable for bilateral pitting edema. Blood sugar finger stick was 412 mg/dl (milligrams per deciliter) and guaiac stool was positive. There was no active gastrointestinal bleed noted. Psychiatric consult was noted and cleared the patient from a psychiatric standpoint with instructions for outpatient follow-up. The patient received insulin per sliding scale and was placed on a cardiac monitor. She was admitted for further evaluation and management of hyperglycemia and uncontrolled diabetes. The patient continued to receive insulin and her home medications were restarted. Physical therapy evaluation was well tolerated and home care services were resumed. The patient was medically stabilized and discharged with instructions to follow-up with her doctors as an outpatient.

Per Crilly et al. (2018), "Results suggest hyperglycemic patients selected by [Emergency Department (ED)] physicians can be managed in the [Emergency Department Observation Unit (EDOU)] setting. Nearly all patients managed in the EDOU for hyperglycemia had an HbA1c9.0%(Hemoglobin A1c), suggesting unrecognized or poorly controlled chronic diabetes as the basis for hyperglycemia." This is further supported by Echouffo-Tcheugui and Garg (2017). As per Echouffo-Tcheugui and Garg (2017), "Evidence suggests that better management of hyperglycemia in the ED with proper follow-up improves clinical outcomes and prevents readmission. Optimization of the hyperglycemia management in the ED may improve clinical outcomes."

Per Fayfman et al. (2017), "Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events."       

Based on the medical facts from the available records, from the perspective of Endocrinology, Diabetes, & Metabolism/Internal Medicine, the patient only had severe hyperglycemia but no evidence of hyperglycemic emergency such as diabetic ketoacidosis (DKA) or hyperosmolar non-ketotic state (HONK). Thus, the inpatient admission is not considered medically necessary as the patient did not meet criteria for inpatient admission. There was no evidence of severe metabolic derangement such has acidosis or renal failure. There was no documented hemodynamic compromise such as hypotension or signs of dehydration.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.                                                        

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.