Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a female with with a past medical history of insulin dependent diabetes mellitus, high cholesterol, hypertension, and seizures.  The patient presented to the emergency department. The patient checked her fingerstick in the morning, which resulted as 197 milligrams per deciliter, and before administering 12 units of Lispro. Later she was found slumped over the couch by her sister and a friend. The patient was reportedly only responsive to voice at that time. The patient was found to be hypoglycemic by Emergency Medical Services and symptoms resolved after intravenous administration of 10 percent dextrose. In the emergency department, the patient was hypothermic to 35.6 degrees Celsius and tachycardic to 114 beats per minute. She denied nausea, vomiting, and diarrhea. The patient was admitted for hypoglycemia. During the hospital course, the patient remained on her home regimen of anti-epileptic medications. She had no further episodes of hypoglycemia and remained seizure free. Computed Tomography of the head was negative for acute findings. Magnetic Resonance Imaging of the brain was negative for acute processes. Rehabilitation was consulted for dizziness reported by the patient. It was noted that the patient has a history of occasional dizziness and safety precautions were reviewed. The patient was discharged with Neurology and Primary Care Provider follow-up.

Per American Diabetes Association (2004) hospital admission guidelines,  in patient admission for hypoglycemia is needed  with blood glucose <50 milligrams per deciliter [<2.8 millimoles per liter and the treatment of hypoglycemia has not resulted in prompt recovery of sensorium; or coma, seizures, or altered behavior (e.g., disorientation, ataxia, unstable motor coordination, dysphasia) due to documented or suspected hypoglycemia; or the hypoglycemia has been treated but a responsible adult cannot be with the patient for the ensuing 12 hours; or the hypoglycemia was caused by a sulfonylurea drug.

Per Bilhimer MH, Treu CN, Acquisto NM. (2017), "Two hundred forty-four patients were included (mean age, 59  18.7 years; weight, 85  24.3 kg). Patients arriving via prehospital care (n = 124) were assessed faster in the emergency department (ED) [median, 25 minutes; interquartile range (IQR), 10-40 minutes] compared with ambulatory arrival (median, 43 minutes; IQR, 17-95 minutes; P = .0018). There were 174 patients with blood glucose (BG) of 50 mg/dL in the ED. Of those, 108 (62.1%) were treated with intravascular bolus dextrose/intramuscular glucagon and 21 patients (12%) did not receive any treatment or food. The overall median time to treatment after identification of hypoglycemia was 12 minutes (IQR, 6-27.8 minutes); treatment was administered faster after bedside point-of-care testing assessment compared with when serum samples resulted [11 (IQR, 6-23.5) minutes vs 25 (IQR, 10.75-42.5) minutes, respectively; P = .015]. The overall time to repeat BG was obtained 22 (IQR, 8-44) minutes after bolus treatment, but this interval increased with subsequent measurements. Refractory or recurrent hypoglycemia occurred in 30.3% of patients. Mean initial BG was lower in the subset of patients who developed refractory hypoglycemia compared with those who did not (35.1  9.8 vs 37.6  10.2 mg/dL, P = .079), although not statistically significant. Patients with recurrent hypoglycemia were also less likely to receive dextrose containing intravenous fluids compared with those without recurrent hypoglycemia (P = .028). Infection was the only associated characteristic with refractory or recurrent hypoglycemia (P = .021)."

Mathew, P., and Thoppil, D. (2021), "Severe insulin reactions can prove fatal, so it is essential to contact EMS immediately when an individual is disoriented or unconscious. Diabetes patients should also reach out to their clinicians if they begin to experience frequent hypoglycemia episodes, as they may need to have adjustments made to the medication regimen, meal plans, or exercise regimen. Non-diabetic individuals who show signs or symptoms of hypoglycemia should contact their clinician for evaluation of the situation. Severe or prolonged hypoglycemia can be life-threatening, and in diabetes patients, there is a correlation with increased mortality. For non-diabetic individuals experiencing reactive hypoglycemia, the prognosis is good."

The patient was found to be hypoglycemic and slumped over couch by paramedics with a point of care glucose of 24 and was promptly given medications to raise blood glucose and she improved to 64 with improvement of awareness. She was sent to the emergency department her plasma glucose 198 and according to the notes she did not require intravenous glucose. During the hospital course, the patient remained on her home regimen of anti-epileptic medications. She had no further episodes of hypoglycemia and remained seizure free. Therefore, the inpatient admission is not medically necessary.

Based on the medical facts from the available records, claim documentation, and any additional information obtained from the patient's treating provider(s) from the perspective of  Endocrinology, Diabetes, & Metabolism/Internal Medicine, the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.                                           

The insurer's denial of coverage for the inpatient admission is upheld.  Medical necessity is not substantiated.