Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetes Mellitus.
Treatment:  Inpatient Hospital Stay.

The insurer denied the inpatient hospital stay.  The health plan's determination is upheld.

The patient is a female, who initially presented to the emergency department with concerns for nausea and dizziness. Her pertinent history included recent diagnosis of diabetes mellitus. Her initial vital signs revealed a temperature of 98.8, heart rate (HR) 96, blood pressure (BP) 118/82, respiratory rate (RR) 18, and her peripheral capillary oxygen saturation (SpO2) was 96 percent (%) on room air. The initial examination documented the patient as alert and oriented. The initial laboratory testing revealed a white blood cell count (WBC) 9.6, hemoglobin 14.6, platelets (Plt) 203, sodium 134, potassium 3.6, blood urea nitrogen (BUN) 9, creatinine 0.94, carbon dioxide (CO2) 17, glucose 425, Anion gap 17 and Beta-hydroxybutyrate was 1.9. For the blood gas, her potential hydrogen (pH) was 7.35, partial pressure of carbon dioxide (pCO2) 35 and bicarbonate (HCO3) was 19. Intravenous fluids and subcutaneous Insulin were provided with improvement in blood glucose and normalization of the anion gap.
The patient was placed in the hospital. The admitting physician had an impression of mild diabetic ketoacidosis and conjunctival injection with plan to rule out cellulitis. The treatment plan included subcutaneous insulin, empiric antibiotics, and a magnetic resonance imaging (MRI) of the orbits.  There were no new issues. The MRI of the orbits was negative for cellulitis, and antibiotics were discontinued. Her hemodynamics were stable, and her diet was tolerated. The serum glucose was 261 and the CO2 was 19. Her subcutaneous Insulin was adjusted. There were no new issues, and her glucose was 155. Endocrinology was consulted whom had an impression of hyperglycemia with possible mild diabetic ketoacidosis, although normal pH. An Insulin regimen recommended. The patient was discharged thereafter.  

Based on the clinical documentation provided, evidence-based literature and standards of care, an acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care with transition to outpatient services. 

The patient had a new diagnosis of diabetes mellitus who presented with nausea and dizziness. The initial examination documented the patient as alert, oriented, and hemodynamically stable. The initial evaluation revealed a glucose of 425, elevated beta-hydroxybutyrate, CO2 17, and a normal pH 7.35. Thus, criteria for diabetic ketoacidosis were not met. The treatment plan included intravenous fluids and adjustments of subcutaneous Insulin. Following observation care, presenting symptoms were improved and/or resolved and serum glucose was adequately controlled. No other issues or complications were documented.
Clinical indications for admission to inpatient care were not met. The patient did not have diabetic ketoacidosis, hemodynamic instability, hyperglycemic hyperosmolar state, mental status changes, severe or persistent dehydration, significant electrolyte abnormality not responsive to observation care, severe or persistent vomiting, or glucose level persistently too high for next level of care (e.g., concern for redevelopment of dehydration, electrolyte abnormality) or not sufficiently stable despite observation care.[3]
 
The health plan's determination of medical necessity is upheld in whole.