Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient hospital. 
The insurer denied: inpatient stay. 
The denial is overturned.  

The patient is a male with history of autism referred by his primary medical doctor (PMD) for elevated glucose and HbA1c. He has generally been well without any fevers, vomiting or diarrhea. The family was away in Florida 3 weeks prior to presentation and the patient's mother noticed since then he has been drinking more and urinating more for the last 3 weeks. He reportedly was drinking anything available. He is not toilet-trained but his mother noted significant nocturnal enuresis. He has not had any weight loss. He went to the Pediatrician where glucose level was elevated in the 500s, normal bicarbonate (HCO3), HbA1c was 10 so he was referred to the emergency department (ED). In the emergency room (ER) Temp was 36.1, heart rate (HR) was 102, blood pressure (BP) was 104/62, respiratory rate (RR) was 18. Upon exam the patient was described as alert, in no distress. Exam was unremarkable. His initial blood glucose level was 315, potential hydrogen (pH) 7.37, bicarbonate (HCO3) 22.9. Normal saline (NS) bolus administered, and Endocrine consult was called. Venous blood gas (VBG) done did not demonstrate acidosis. Glucose improved to 197 after NS Bolus. Endocrinology was consulted for management of new onset diabetes mellitus (DM). They recommended 5 units (U) of Lantus and they would work on developing a sliding scale. They recommended admission.

The health plan's determination is overturned in whole. 

This patient presented with new onset diabetes but with a more complex situation as he is autistic. He did not meet the standard criteria usually outlined for new onset diabetes as he was not in diabetic ketoacidosis (DKA) nor did he have any signs of clinical instability evidenced by stable vital signs as well as no vomiting, diarrhea or altered mental status. Despite this and from reviewing the notes provided there were social concerns regarding a safe discharge for this patient as well as the concern that this patient, due to his autism, would not communicate effectively if he were to experience any symptoms associated with hypoglycemia or hyperglycemia. Inpatient admission for intensive diabetes education as well as ensuring that the caregivers would be able to provide adequate control of the patient's clinical needs is of utmost importance in this case. Nurse's assessment at the time of discharge reported parents demonstrated poor technique and required re-guidance multiple times during blood sugar check. They also demonstrated poor skills in administration of insulin as the patient was difficult to hold down and keep still. Nurses expressed concern about the safe discharge of this patient. Inpatient admission at times becomes medically necessary when social or logistical concerns exist as they may greatly impact the child's health. This would a significant concern in this case as without education on how to carefully manage new onset diabetes, the consequences may be serious for the patient. Hospital admission guidelines for diabetes per the American Diabetes Association report inpatient care may be appropriate in certain situations and they go on to include "Newly diagnosed diabetes in adolescents and children". For these reasons, inpatient level of care would be necessary to safely care for this patient.