Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is overturned

This is a patient with a past medical history which includes diabetes mellitus, chronic kidney disease, hypertension, alcohol-induced pancreatitis, asthma, back pain, cerebral vascular accident, eczema, tobacco abuse, substance abuse, medical non-compliance, and seizures. She had recently been admitted to another hospital with hypoglycemia. On the day of admission, her son called emergency medical services (EMS) because the patient had confusion with low blood glucose, and she was transported to a hospital. There, she was initially found to have blood glucose level of less than 20 mg (milligrams) /dL (deciliter) (reference range is 74-105), despite initial treatment by EMS which included a dextrose infusion. She had responded to Narcan in the ambulance (although the tox (toxicity) screen was subsequently negative for opioids, but positive for cocaine), and responded to intravenous dextrose solution in the emergency department (ED). 

She was admitted to the hospital. At the time of this evaluation, the patient was cooperative. Recent insulins included Lantus and Lispro (half-lives of 12 hours and 3 hours, respectively). Medications were noted to be different in each of her previous recent hospital admissions to other institutions. Recent transfusion due to an unexplained drop of 6.6 g (grams)/dL (deciliter) in her hemoglobin level was noted. She was anemic at the time of this admission, with a Hgb (hemoglobin) of 10.0 and HCT (hematocrit) of 31.7; this was an improvement from the previous day, with H&H (hemoglobin and hematocrit) of 8.6 and 25.0; similar low values were noted again the following day. 

The plan did not act reasonably and with sound medical judgment and in the best interest of the patient. While many patients with new-onset atrial fibrillation do not require an admission, as many as 2/3 are routinely and appropriately admitted to the hospital from the ED with this diagnosis. An older, commonly cited reference indicates that admission is justified if a diagnosis other than new-onset AF (atrial fibrillation) also warranted admission, or if there are complicating factors in the ED or subsequently. 

By any of these criteria, or by many of the criteria summarized above in MCG (Milliman Care Guidelines) 25th Edition, the patient was a reasonable and appropriate candidate for admission. She had multiple comorbidities, her presentation was complicated by other diagnoses that warranted admission (including a non-detectable blood glucose level and altered mental status due to metabolic encephalopathy, which had not completely resolved by the time of admission), she had received a long-acting insulin, and she was clearly still symptomatic after ED evaluation and treatment.

The inpatient emergency admission was medically necessary for the patient. Specifically, she demonstrated continued high risk and incomplete resolution of her presenting issues at the time that admission was being considered.

The insurer's denial of coverage for the inpatient emergency admission is overturned. Medical Necessity is substantiated.