Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Diabetes
Treatment: Inpatient Hospital

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with an unremarkable past medical history who presented to the hospital with complaints of blurry vision for 3 weeks. The patient endorsed polyuria, polydipsia, and an unintentional weight loss over the course of 1 year.
The review of systems obtained at the time of admission was negative for any eye problems. Specifically, she denied any pain in the eyes, discharge, redness, photophobia. The patient denied any tingling, numbness, weakness in her fingers, or toes. She also denied nausea, vomiting, diarrhea, increased urinary frequency or urgency, dysuria.
When the patient was seen by the admitting physician, she was afebrile. Her blood pressure was 125/85 millimeters of mercury (mmHg), with a pulse rate of 88 beats per minute (bpm), a respiratory rate of 18 breaths/minute, and an oxygen saturation was 99% on room air. Her body mass index (BMI) was 32.78. The patient appeared to be a well-developed obese female who was resting comfortably, in no acute distress. She was awake, alert, and oriented x3. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The patient was able to move all 4 extremities. She had no edema. The neurologic exam was unremarkable.

The patient was admitted to the hospital with a diagnosis of newly diagnosed diabetes mellitus.
Her symptoms such as blurry vision, polydipsia, polyuria, and unintentional weight loss were attributed to diabetes mellitus. The patient was started on injections of long-acting insulin as well as Metformin. In the hospital, she was seen by an ophthalmologist who diagnosed the patient with cataracts that were attributed to diabetes mellitus and metabolic abnormalities. The ophthalmologist recommended outpatient assessment for the possible intervention for cataracts.
Since the patient's symptoms improved and her serum blood sugars came down, she was transitioned to outpatient care.
At issue is the medical necessity of the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records clearly demonstrated that the patient had no overwhelming evidence of diabetic ketoacidosis or hyperglycemic hyperosmolar state.
The patient's hyperglycemia was not associated with hemodynamic instability, severe or persistent altered mental status, severe or persistent dehydration, vomiting, significant electrolyte abnormalities. The patient was able to maintain oral hydration. There was no evidence that the hyperglycemia was triggered by any underlying conditions including infection.
Therefore, after a short period of observation and teaching the patient insulin injection technique, she could have been discharged from the hospital. In general, according to the medical records, the patient's hospitalization was relatively short.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at an alternate level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.