Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient has a past medical history significant for hypertension, type II diabetes mellitus, and schizophrenia who presented to the psychiatric emergency department with complaints of hearing voices. At the time of the initial evaluation, he was found to have elevated blood sugar levels. According to the history and physical (H&P) note, the patient denied any suicidal or homicidal ideations. He also denied fever, cough, chest pain, dysuria, abdominal pain, or vomiting. Because of significant hyperglycemia, the patient was admitted to the hospital.
When seen by the admitting physician the patient was afebrile, blood pressure was 144/86, pulse rate 95 beats per minute (bpm), respiratory rate 17 breaths/minute, and oxygen saturation was within normal limits. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular hear rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 5.4, hemoglobin 12.9, hematocrit 37.9, and platelets 198. The sodium was 135, potassium 3.9, chloride 100, bicarbonate 24, blood urea nitrogen (BUN) 12.6, and creatinine 0.86. The creatine phosphokinase (CPK) and troponin were normal.
The patient was admitted to the hospital with hyperglycemia, uncontrolled diabetes mellitus, hypertension, schizophrenia, and obesity. In the hospital, the patient was treated with a combination of long-acting and short-acting insulin.
He was seen by a psychiatrist who recommended admission for safety.
The patient was also seen by an endocrinologist who confirmed the diagnosis of uncontrolled diabetes mellitus due to medication and diet non-adherence. The endocrinologist suggested adjusting the doses of short-acting and long-acting insulin.
During the short hospital stay, the patient remained in satisfactory clinical condition and was transitioned to the inpatient psychiatric unit the next day after the day of admission. At issue is the medical necessity of the inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with complaints of hearing voices telling him to hurt himself and others. However, it was indicated in the H&P note that the patient had no suicidal or homicidal ideations. This patient did not require admission at the acute inpatient level of care for treatment of uncontrolled diabetes mellitus since there was no evidence that the patient had diabetic ketoacidosis, hyperglycemic hyperosmolar state, or severe symptoms associated with high blood sugars such as altered mental status, significant dehydration, persistent nausea, or vomiting.
Taking into consideration all of this information, there was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. Overall, he remained in stable clinical condition with improvement in hyperglycemia. This patient did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.