Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Endocrine/Metabolic/Nutritional. 
Treatment:  Inpatient Hospital. 

The insurer denied the inpatient hospital admission.  The denial is upheld in whole. 

The patient is male with a past medical history significant for type 1 diabetes mellitus, gastroparesis and depression, who was brought to the emergency department from an assisted living facility with complaints of high blood sugars and diffuse abdominal pain.  At the time of the initial evaluation, the patient denied any vomiting or diarrhea.  His review of systems was positive for weight loss and polyuria.  The rest of the review of systems was negative.

Laboratory evaluation revealed that the patient was afebrile, blood pressure was 106/81, pulse rate 102 beats per minute (bpm), respiratory rate was 20, and oxygen saturation was 96% on room air.  The patient was in no acute distress.  Head, eyes, ears, nose, throat (HEENT) exam was unremarkable except for dry conjunctiva.  The neck was supple.  The patient had full range of motion.  Lungs were clear to auscultation bilaterally without wheezing.  The cardiovascular exam was within normal limits.  The abdomen was soft, nontender, with normal bowel sounds.  The patient had normal peripheral pulses and no edema.  The neuro exam was within normal limits.  Laboratory evaluation revealed white blood cell count was 5.88, hemoglobin 17.0, hematocrit 48.4, and platelets 310.  Sodium was 135, potassium was 4.8; chloride was 92; bicarbonate was 31; brain natriuretic peptide (BNP) was 15; creatinine was 1.0, and glucose was 621.  Liver function tests were within normal limits.  The urinalysis was negative.  The patient was admitted with a diagnosis of hyperosmolarity associated with type 1 diabetes mellitus.  The patient received treatment with intravenous fluids and a combination of long and short-acting insulin.  During the hospital stay, the patient's clinical condition improved quickly.  According to the progress note, the patient felt better overall and denied abdominal pain, diarrhea, and vomiting.  As a result of the treatment provided in the hospital, the patient's clinical condition significantly improved.  His blood sugars normalized.  The patient tolerated his diet.  He was deemed stable to discharge back to assisted living.  The subject under review is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The inpatient hospital admission was not medically necessary.  The patient presented to the hospital with complaints of abdominal pain and elevated blood sugars.  At the same time, the laboratory evaluation was not consistent with diabetic ketoacidosis, since the patient had normal pH, normal bicarbonate level, and high normal anion gap.  There was no clinical evidence of hyperosmolar hyperglycemic state.

The review of the medical records did not demonstrate that patient's hyperglycemia led to severe dehydration, kidney failure, or significant electrolyte abnormalities.  The patient's clinical condition improved very quickly, and significantly better glycemic control was achieved within a short period of time.

There was no evidence that the patient had a concomitant condition necessitating admission at the acute inpatient level of care.  Overall, the patient required treatment with intravenous fluids for a relatively short period of time.  According to the history and physical (H&P) note, the patient was started on a combination of long-acting and short-acting insulins and did not require administration of intravenous insulin.

Taking into consideration all these facts, admission to ensure improvement in the patient's symptoms and improvement in blood glucose control was medically necessary, however, not at the inpatient level.  The patient could have been appropriately treated at a lower level of care status.

Neither the severity of the patient's condition nor the complexity of the services provided rose to an acute inpatient level of care.