Appeal type: Medical necessity
Decision: Upheld

Diagnosis: 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 who was admitted with the diagnosis of new onset diabetes (likely type 2). She has a strong family history of diabetes and her father; paternal and maternal grandmothers have been diagnosed with diabetes. Her father is on insulin. She is grossly obese, and her weight was 88 kg (kilograms) [body mass index (BMI) +3.13 standard deviation (SD)]. She has been followed by her primary care provider for obesity and her glycated hemoglobin (HbA1c) was 10.1% and 10.9%. She was having excessive urination and excessive drinking but no weight loss. She was finally referred to a pediatric endocrinology clinic.
In the pediatric endocrinology clinic, her fingerstick glucose was 351 mg/dl (milligrams/deciliter) for which she was referred to the emergency department (ED). In the ED, her glucose was 321 mg/dl, with a bicarbonate of 24 millimoles/liter (mmol/L), a potential hydrogen (pH) reading was 7.38 and the urine was positive for glucose but negative for ketones. She received normal saline bolus in the ED and her repeat glucose was 269 mg/dl. She was admitted from the ED to the pediatric floor for acute inpatient care.

The patient was started on Metformin before breakfast and dinner, long-acting insulin at bedtime and rapid acting insulin for food coverage and correction for high blood sugars. She was discharged.

At issue is the medical necessity for the inpatient stay.

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

No. This patient did not meet the criteria for acute inpatient care.
The most important aspect of management of type 2 diabetes is lifestyle changes with diet and exercise. Metformin is considered the initial drug of choice. This patient was admitted in the hospital for inpatient acute care to control hyperglycemia and initiation of insulin treatment. Initiation of insulin seems reasonable considering the fact that her HbA1c was over 10%; however, as she did not have any sign or symptom (such as vomiting, abdominal pain, fever, rapid shallow breathing, altered mental status) or lab findings (such as acidosis, ketosis, hyperosmolality) to suggest acute risk for decompensation; she should have been cared for under an alternate level of care.
Diabetes mellitus is a chronic disease that requires continuous medical care. The management plan for diabetes should include education for self-management and ongoing support to improve control which can prevent acute and long-term complications. A variety of strategies and techniques are used to provide adequate education and development of problem-solving skills in the various aspects of diabetes management that may require hospitalization. Usually, the treatment goals and plan are individualized taking into account patient preferences.
Until 2009, the diagnosis of diabetes was based on plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-hour value in the 75-gram oral glucose tolerance test (OGTT). In 2009, the International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended the use of the HbA1c test to diagnose diabetes, with a threshold of 6.5%. ADA adopted this criterion in 2010.
This patient is grossly obese and has a strong family history of diabetes. Her father has been diagnosed with diabetes and on insulin. She had no weight loss at the time of admission, her pH was 7.38 and the bicarbonate was 24 momol/L ruling out acidosis, and her urine was negative for ketones. Clearly, her clinical picture was consistent with type 2 diabetes, and she was not at risk of acute decompensation.