Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 1 Diabetes.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This patient is a female with a history of type one diabetes mellitus (T1DM) diagnosed. The patient was brought to the emergency department for tremulousness and hypoglycemia. The patient was found to be not oriented and confused and so she was given a glucagon at home and her symptoms gradually improved. On arrival of Emergency Medical Services (EMS), the patient's glucose was 189. She had a recent similar episode. The patient was admitted to the emergency room (ER) and discharge. 

The patient is on 34 units of Basaglar and uses an insulin to carbohydrate ratio of one to eight (1:8). Her vital signs were stable with a pulse of 118. The emergency room contacted the endocrinologist who confirmed the insulin dosing and added that the Insulin Sensitivity Factor (ISF) was 1 to 60 with a target 120. The patient's sodium was 133, potassium was 3.8, chloride was 101, calcium was 8.5, anion gap was 6, glucose was 231, blood urea nitrogen (BUN) and creatinine were normal. The patient's pH (potential of hydrogen) was normal at 7.38 with a bicarbonate of 27.7. The patient had missed appointments at the endocrinology clinic. She was also found to have a low hemoglobin and hematocrit at 10.1 and 31.4. During the hospitalization the patient's dose of Lantus was reduced to 20 and her insulin to carbohydrate ratio was reduced 15. The patient and parent received some education about her insulin regimens well as treating hypoglycemia.

No, the proposed inpatient admission was not medically necessary.
Diabetes education consists of several components, nutritional counseling, self monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components  [1, [2].  Practice patterns differ depending on the availability of educators etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the United States [3] that treat new onset type I diabetes admit their patients. According to the American Diabetes Association (ADA) statement on treatment of type I diabetes [4, [5, [6, [7], 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 II diabetes. Indications for admission for new onset type II 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 I 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. 

However, this patient has already received diabetes education at onset of her diabetes. The patient came to the hospital for hypoglycemia. The patient's regimen was unknown at first and needed adjustments given the hypoglycemic episode. The patient and her mother needed education for how to treat hypoglycemia. This could have been achieved in an observation overnight admission where the patient's doses were adjusted and diabetes education delivered. Acute inpatient admission for three days is not consistent with generally accepted standards of medical practice for patients with known diabetes who do not have diabetic ketoacidosis (DKA). The request is therefore not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient as the requested hospitalization was not medically necessary as described above.