Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness, Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

The patient is a female with a history of hypothyroidism, who presented to the emergency department (ED) for dizziness and chest pain. The review of systems was positive for fatigue and weight changes related to Ozempic use.
The patient was afebrile. Her vital signs were stable. The patient was in no apparent distress. Physical examination was remarkable for an anterior neck mass and bilateral ankle edemas.
The patient was admitted for chest pain and uncontrolled hyperglycemia. Her glucose was 406. The patient is a known diabetic and has not been able to take medications or have follow-up due to insurance issues.  The patient was initiated on long and short acting insulin. She was also found to have new onset heart failure (HF) with an ejection fraction (EF) of 30-35 percent (%). Given the presence of chest pain, the patient underwent a stress test that showed mild ischemia. The patient was discharged and scheduled for outpatient catheterization. Of note, the patient had hypothyroidism with a thyroid stimulating hormone (TSH) of 21 and was restarted on Synthroid. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was medically necessary. The care could not have been safely rendered at a lower level of care.
The documentation supports an inpatient level of care based on the presence of clinical signs of uncontrolled hyperglycemia and hyperosmolar state. The indication for inpatient admission was largely related to the fact that the patient had poor outpatient follow up and was non adherent to medications. As such, the admission is justified based on the need for treatment of hyperglycemia with subcutaneous (SC) insulin and establishment of a long-term regimen. The hospitalization was complicated by findings of new onset heart failure in the setting of chest pain and lower extremity edema. Additionally, the patient had a positive stress test with evidence of ischemia. Inpatient level of care was warranted for echocardiogram, stress test, insulin therapy and expert consultations with cardiologist and endocrinologist.
Diabetic ketoacidosis (DKA) or hyperosmolar state can be a life-threatening medical emergency. As such, inpatient level of care for intravenous (IV) fluids, electrolyte stabilization/monitoring and intravenous insulin were necessary for the entire length of stay. Without proper hydration and aggressive insulin treatment, patients can rapidly enter the DKA phase requiring an intensive level of care or insulin drip and close monitoring.
Hyperglycemia and new onset diabetes can be managed on an outpatient basis. Hospital admission is only necessary if intravenous therapy is required to correct dehydration, electrolyte imbalance, and ketoacidosis, with progression to oral fluids and subcutaneous insulin administration as the patient's condition improves. The American Diabetes Association also provides guidelines for determining when a patient requires hospitalization for reasons related to diabetes. Inpatient care may be appropriate for patients with hyperosmolar metabolic state and patients with poor outpatient follow up.