Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Endocrine/Metabolic/Nutritional/Other/High Blood Sugars
Treatment: Inpatient Stay
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is upheld.

The patient is a female child with an unremarkable medical history who was referred to the emergency department (ED) by her pediatrician for evaluation of an elevated blood glucose. She had bloodwork done approximately a week prior and a non-fasting blood glucose was 199 (one hour after eating) and her hemoglobin A1C was 9.5. She was otherwise well with no complaints. Family history was positive for diabetes in her mother, brother, and grandmother. Physical examination was unremarkable. Bedside glucose was 199. Laboratory evaluation was significant for a glucose of 187 and an alkaline phosphatase of 357, otherwise, there were unremarkable metabolic labs and an unremarkable complete blood count. She was given a liter bolus of normal saline and was admitted for evaluation of a new-onset of diabetes mellitus, not in diabetic ketoacidosis (DKA).
Additional history was obtained at admission, including a weight gain of 50 pounds over the past two years, sedentary lifestyle, possible polydipsia and polyuria but had a history of urinating a lot. Admission examination was significant for obesity with acanthosis nigricans on her neck bilaterally and in her axillae. Rapid viral screening was negative. Urinalysis was significant for a specific gravity of 1.033, negative ketones, a glucose of 100, and no signs of infection. Repeat bedside glucose measurements were 121 and 231. Admission orders included Lantus 12 units at bedtime, accuchecks before each meal with a target glucose of 120, insulin:carbohydrate ratio 1:15, insulin correction factor 50, additional laboratory studies in the morning, and an Endocrinology consultation (already completed). Repeat hemoglobin A1C was 8.9. Her diagnosis (type 1 or type 2) was not completely clear, but more consideration was given to type 1 diabetes, given her age. Diabetes education was provided to both child and mother and she was given a clinic appointment to follow-up. She was deemed stable for discharge 
 At issue is the medical necessity for the requested health service/treatment of the inpatient stay. 

The health plan's determination is upheld, in whole.

No, this child did not require an acute inpatient stay. This preteen female child with strong family history of diabetes was referred to the ED for evaluation of hyperglycemia and elevated hemoglobin A1C. She was questionably symptomatic, with possible polyuria and polydipsia, but no signs or symptoms of diabetic ketoacidosis. She was admitted for diagnostic studies, diabetes education, and initiation of insulin therapy. In the absence of DKA, the majority of diabetes management including education occurs in the outpatient setting unless there are issues with compliance. In this child's case, she was clinically stable, barely symptomatic from the hyperglycemia, and her mother was already educated in the management of diabetes. She did not require acute inpatient admission and could have been safely managed at an alternate level of care.