Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abdominal Pain, Headache and Diarrhea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned, in part.

The patient is a female with a history of type II diabetes. At home, the patient was prescribed basaglar and Admelog sliding scale as well as metformin. She presented to the emergency department with hyperglycemia dysuria, polyuria, with Lantus given prior to ED (emergency department) arrival. She had abdominal pain with cramps and diarrhea over the previous several days.

In the ED (emergency department), the patient was tachycardic with abdominal pain, nausea, diarrhea, polydipsia, polyuria, dysuria, urgency, headaches. Her glucose was 422, A1C (glycated hemoglobin) was greater than 14. She had ketones in the urine. She was treated with intravenous saline. The patient was admitted for diabetes management and education. The patient had lost 20 pounds in approximately the last four months. The patient reported glucoses over 400 for the previous 2 weeks. She also had enuresis. Her bicarbonate was 22. Sodium was 138. Potassium was 4.2. Creatinine was 0.81. Urine ketones were 80.

The patient received a normal saline bolus. She was started on Lantus and admitted with an endocrinology consult. The patient and her aunt received diabetes education as she was living away from her parents at the time. The patient was transferred back to her biological mother's care and lives with her mother and two younger brothers. The patient's mother needed new onset diabetes teaching. The patient's mother did not complete diabetes teaching in a timely manner during this hospitalization.

Yes, in part. The Inpatient admission was medically necessary, in part. Specifically, the inpatient admission for the last three days of admission was medically necessary.
Practice patterns differ depending on the availability of educators, etc. Whether a patient is hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the US (3) that treat new onset type 1 diabetes admit their patients. According to the ADA (American Diabetes Association) statement on treatment of type 1 diabetes (4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education." That is not the case for type 2 diabetes. Indications for admission for new onset type 2 diabetes are more stringent and dependent upon the presence of symptoms such as ketosis, dehydration, hyperosmolarity, vomiting and inability to maintain hydration or severe metabolic/electrolyte abnormalities. In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a two-to-three day admission to the hospital.

The patient in this case has diabetes that was diagnosed a year prior to admission. The patient's family at the time had education. The patient is now with her biological mother, who has not had education. The patient presented with severe hyperglycemia, weight loss, and ketosis. This required admission for hydration. Given the fact that the patient's mother does not know how to administer insulin properly and has not had full education, continued admission beyond observation was clinically appropriate and consistent with generally accepted standards of medical practice. However, there was a delay in providing the education to the mother. Education does not require five days. The family could have been educated on diabetes management, with discharge on day five. Inpatient admission was therefore medically necessary the remaining three days of admission.