Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Sugar
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is a teenage male with history of pre-diabetes, obesity, admitted for new onset Type 2 Diabetes Mellitus (T2DM). The patient was previously prescribed Metformin for pre-diabetes at another hospital. On the day of admission, he presented to the emergency department (ED) with 4-day history of polyuria, polydipsia, nocturia, headaches, dizziness. Blood glucose at home was in the 300-400s range.

The Inpatient Hospital Admission was medically necessary.

The American Diabetes Association (ADA) recommends that diabetes self-management skills and need for support should be assessed for all diabetes patients admitted to the hospital, and that diabetes self-management education support (DSMES), should be provided when a need is identified (1).

Diabetes organizations have provided recommendations for the provision and content of diabetes education in the hospital (1). The consensus recommendation for inpatient education is to provide content focused on "survival skills" that will prepare patients for discharge and enable them to safely manage their diabetes at home until they are able to receive more detailed instructions in the outpatient setting. Survival skill self-management education will convey basic self-care information 
to include the following: An understanding of the diabetes diagnosis; ability to monitor glucose at home; identification of individual glycemic goals; recognition, prevention, and treatment of hypoglycemia and hyperglycemia; basics of a healthy meal plan for optimizing glycemic targets; how/when to take prescribed diabetes medications, including insulin, their mechanisms of action, and if relevant, home sharps disposal; sick day rules; and when to call a health care provider or go to the Emergency Room or Urgent Care. In addition, inpatient diabetes education includes a discharge plan that ensures continuity of care by providing referrals to outpatient diabetes education and/or providers.

Given the rising numbers of hospital admissions that include a diabetes diagnosis, and the knowledge that a significant proportion of persons with diabetes do not receive appropriate outpatient diabetes self-management education support (DSMES), hospitalization does present an opportunity to provide knowledge through delivery of survival skills education to help assure safe and effective self-care management, decrease readmission rates, and improve allied diabetes- related outcomes. The consensus recommendation for inpatient diabetes teaching is to provide survival skills education to enable safe self-management following discharge until more comprehensive outpatient education can be provided (2).
Patients with diabetes have high hospitalization rates both for diabetes-related and non-related diagnoses and higher rates of 30-day readmissions when compared with persons without diabetes. Readmissions can be partially attributed to deficits in diabetes knowledge and self-management skills, including taking diabetes medications as prescribed. Therefore, hospital admissions present a critical opportunity not only for appropriate diagnosis and treatment but also for providing self-management education to persons with diabetes (3).
Accumulating heterogeneous body of evidence suggests that inpatient diabetes education, improving communication of discharge instructions, and involving patients in medication reconciliation may reduce risk for early readmissions (4) and improve health outcomes (5,6). This patient presented with new-onset diabetes mellitus needing initiation of multiple daily insulin injections to control blood sugars and prevent complications. As such, patient and family had a significant amount of diabetes education needs that had to be addressed before patient could be discharged home safely. 

Hence, the Inpatient Hospital Admission was medically necessary.