Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity 
The denial was upheld.

This patient is a male with a history of type 1 diabetes and hypertension, who presented to the emergency department with abdominal pain, chest pain, and testicular pain. The symptoms were present for 1 week, described as intermittent, dull, aching, and non-radiating pain in the chest, abdomen, and testicles. He experienced 1 bout of non-bloody emesis. The patient reported diarrhea that had been ongoing for months. He denied any fevers, chills, shortness of breath, or cough.
On general exam findings, the patient had no dehydration evidence, no jugular vein distention (JVD); the cardiac exam showed regular rate and rhythm. There was no lower extremity edema, and lungs sounded clear. The abdomen was non-distended and non-tender to palpation. Neurologically the patient was intact.
A twelve-lead electrocardiogram (EKG) showed normal heart rate. The chest x-ray was clear. The complete blood count (CBC) showed normal white blood cell count and hemoglobin. His sodium was slightly low at 130, and creatinine was1.26. Results of the urinalysis showed no ketones, and negative leukocyte esterase.
The patient was admitted to the hospital with chest pain unspecified, unspecified abdominal pain, and diarrhea per the medical team documents, and atypical chest pain likely due to musculoskeletal in origin. Cardiac troponin was 0.03. They ordered serial troponins. The medical team documented acute kidney injury due to dehydration. They report baseline creatinine less than 1, currently at 1.26. The patient was treated with intravenous (IV) fluids. Regarding diarrhea, stool studies were sent, a celiac panel was sent, and gastrointestinal (GI) was consulted. For the testicular pain, the medical team documented no evidence of epididymitis or orchitis. They ordered mumps antibody and a sexually transmitted disease (STD) work-up, along with a testicular ultrasound.
An endocrinology consult was obtained for the patient's type 1 diabetes,  noting that blood glucose values were improving. Per the documentation, initial blood glucose was 729, decreasing down to 345. The last glycated hemoglobin (A1C) was 15.5, and the current one was pending. No evidence of diabetic ketoacidosis (DKA) per the endocrinologist. The insulin regimen was adjusted. Repeat chemistry panel showed the creatinine has improved down to 0.83, and the sodium was 134.
The gastroenterology team also assessed the patient and reported the patient had watery, non-bloody diarrhea with 3-4 episodes per day with associated weight loss over several months. The last documented endoscopic evaluation was 5 months before this presentation, showing moderate gastritis and Helicobacter (H) pylori, treated with clarithromycin and metronidazole. Hemoglobin was stable. The abdomen's imaging was reviewed, including a computed tomography (CT) scan of the abdomen and pelvis, which showed no evidence of acute abdominal pathology. They concluded the patient may need colonoscopy and biopsy. The stool panel was pending.
The testicular ultrasound was grossly unremarkable. The medical team noted, the patient had similar bilateral testicular tenderness, with unremarkable imaging. The 3 sets of cardiac enzymes remained negative; therefore, the acute coronary syndrome was excluded. The renal function resolved, and hypokalemia was corrected.
The following day, the patient remained stable. He continued with complaints of diffuse abdominal pain and testicular pain and denied any penile discharge. Surgery was consulted for testicular pain, who ordered tumor markers to rule out testicular cancer. The medical team anticipated discharge the following day.
The patient's condition was stable. The endocrinologist concluded the patient has diabetic neuropathy and gastroparesis as the cause of the abdominal discomfort. He was started on gabapentin and metoclopramide. The stool studies were not available for review. The testicular pain, was concluded, was part of the peripheral neuropathy pattern and not related to any anatomic pathology. The insulin dose was adjusted. The patient was set up with multispecialty follow-up and released home.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.
The patient presented to the hospital with chest pain, abdominal pain, and testicular pain. He was ruled out for an acute coronary syndrome with serial cardiac enzymes. It was reasonable to observe the patient overnight for serial cardiac troponins, and telemetry monitoring, however, clinical inpatient indications were not satisfied due to a lack of evidence of acute coronary syndrome and a need for advanced cardiac testing.
From the standpoint of uncontrolled diabetes, the patient is a Type I diabetic with an elevated A1C, who was currently not in diabetic ketoacidosis. The patient had hyperglycemia; however, there was no evidence of ketonuria or severe acidosis. There was no evidence of hemodynamic instability or elevated anion gap. The patient had mild dehydration, as evidenced by the bump in the creatinine, which resolved with IV fluids within 24 hours of hospitalization. In regard to electrolyte derangements, the patient had mild hyponatremia. When the sodium level was corrected for hyperglycemia, the actual value was 142.
Finally, for the abdominal pain and testicular pain, the patient had imaging on arrival, with a CT scan of the abdomen and pelvis, which failed to demonstrate any acute anatomic pathology. There was no documentation of peritoneal signs. The patient was hemodynamically stable. There was no documentation of ongoing vomiting and dehydration. The white blood cell count was normal, and there was no evidence of sepsis.
In conclusion, the acuity of presentation does not satisfy clinical indications for inpatient care. Therefore, the requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.