Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is a patient a with past medical history (PMH) of chronic kidney disease (CKD), diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), and obesity. He was sent to the emergency department (ED) from the physician's office for complaints of worsening shortness of breath (SOB) and cough of 3 days duration.  The patient was found to have oxygen (O2) saturations 94% (percent) on room air. At triage, the vital signs were blood pressure (BP) 210/111, respiratory rate (RR) 22 and O2 saturations at 93% on room air.  The patient was in no acute distress (NAD). There was no jugular venous distension. Lungs were clear. Cardiovascular system was normal. The patient was alert and oriented to person, place, and time. The Neurology exam was unremarkable.  The patient was given intravenous (IV) labetalol following which BP improved to 180/10. The patient was noted to have hypoglycemia with blood glucose 41. The patient was treated with Dextrose with improvement.  Labs were White blood count (WBC) was 11.4, Blood urea nitrogen (BUN)/ creatinine (Cr) 72/9.25 (Baseline Cr was 5-6).  
Chest x-ray (CXR) bibasilar hazy opacity. Computed tomography (CT) Chest showed right lower lobe (RLL) sub segmental atelectasis. The patient was continued on meds for his Hypertensive Urgency/Emergency with Hydralazine and Labetalol IV.  The patient was admitted to hospital for acute kidney injury (AKI) on CKD (chronic kidney disease) and Hypertensive Urgency/Emergency. The patient also had Hypoglycemia at presentation

The patient was evaluated by Renal, and Endocrine. Medications and diabetic regimen was adjusted to prevent Hypoglycemia. The patient underwent diagnostic studies to rule out Obstructive Uropathy. A CT and Sonogram revealed medical renal disease. There was no obstruction. The patient had some signs of volume overload in the form of pedal edema. Renal recommended IV Lasix after ruling out obstruction. The patient did not have signs of Uremia so hemodialysis (HD) was held.  Endocrine was adjusting his diabetic regimen as his Cr had dropped significantly and he was at great risk for hypoglycemia. The patient's BP was also fluctuating so he needed close monitoring to avoid complications from Hypertensive Urgency/Emergency.

The patient underwent close monitoring of intake and output (I and O), BP and Renal function. If there was deterioration, then he may have needed urgent dialysis. Myocardial infarction (MI) was ruled out. Troponins likely elevated secondary to Renal disease.

Given multiple medical issues and significant deterioration of renal condition which was further impacting his glycemic control it was appropriate to keep patient in the hospital till stabilized. The patient was stabilized and ultimately discharged home with close follow up (F/U) in outpatient setting. This patient was not stable enough to be managed in any other setting till he was stabilized.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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