Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is reversed. 

This patient is a male with no past medical history.  He presented to emergency room (ER) with complaints of reported weakness for several days. His blood sugar level was checked had dropped from 137 to 57. Labs were done included c-peptide 1.0, insulin level of 5 and blood glucose was thought to be in the 80s. The patient had resolution of symptoms with drinking juice/gatorade, hence fulfilling Whipple's triad. The patient has no history of diabetes mellitus (DM). He was admitted and plans were instituted at the direction of the Endocrinology Service was, every 4 hour finger sticks with additional labs if blood glucose was less than 50. The patient's friend had noted possible seizure like activity prior to admission raising the question for whether this activity could have been due to low blood glucose.

"Low blood glucose concentrations lead to adrenergic activation and neuroglycopenia (Table 1). Symptomatic hypoglycemia is diagnosed clinically using Whipple's triad: symptoms of hypoglycemia, plasma glucose concentration<55 mg/dl (3.0 mmol/l), and resolution of those symptoms after the plasma glucose concentration is raised. Capillary blood glucose measurements should not be used in the evaluation of hypoglycemia due to poor accuracy." (Desimone, M.E., and Weinstock, R.S., 2018).

"We reviewed the charts of 591 patients meeting inclusion criteria. Of these 591 patients, 99 (17%; 95% confidence interval, 14-20%) were classified as iatrogenic. Of these 99 patients, 61 (61%) cases of hypoglycemia were caused by insulin administration and 38 (38%) were caused by unrecognized malnutrition. Of the 61 patients with iatrogenic hypoglycemia after ED insulin administration, 45 and 15 patients received insulin for hyperkalemia and uncomplicated hyperglycemia, respectively The most frequent cause was insulin administration for hyperkalemia and uncomplicated hyperglycemia. Additionally, patients at risk of hypoglycemia in the absence of insulin, including those with alcohol intoxication or poor nutritional status, should be monitored closely in the ED." (Chittineni, C., Driver, B. E., Halverson, M., Cole, J. B., Prekker, M. E., Pandey, V., Lai, T., Harrington, J., Zhao, S., & Klein, L. R., 2019).
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Given the possible seizure activity and the blood glucose level of 57 with symptoms, it was reasonable to initiate a fasting test to rule out insulinoma. The patient decided to leave against medical advice (AMA) so the test was never completed.      

The patient had possible neurologic symptoms such as seizure and a history of unexplained hypoglycemia without use of insulin or insulin secretagogues. Evaluating for possible insulinoma with a fasting test as planned was medically necessary and reasonable. Therefore, the inpatient hospital admission is considered medically necessary for this patient.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.