Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure activity due to refractory hypoglycemia and possible opioid intoxication. 
Treatment: Full hospital admission. 

The insurer denied coverage for the full hospital admission. 
The denial is overturned. 

This is a male patient who presented to the Emergency Room (ER). The patient had complaints of seizure and altered mental status. He had a history of methadone dependence, heroin abuse, diabetes, hypertension, hyperlipidemia, and obesity. The patient was noted to have seizure-like activity with loss of consciousness and sliding onto the floor. There was no report of major head trauma. However, the patient had a small abrasion on the right eyebrow. The patient was reported to have low fasting sugar by basic life support crew. 

On arrival to the ED, the patient was obtunded, cool/clammy, and unresponsive to tactile stimuli. His vital signs were documented as blood pressure 150/85, temperature of 97.3 degrees Fahrenheit, pulse of 82, respiratory rate of 24, and oxygen saturation of 98%. He received 2 ampoules of dextrose solution (D50) for a blood glucose level of 17. There was a rapid return of mental status. The patient reported not eating any meals all day. He utilized short acting insulin with the last dose being the previous night. The patient was a low suspicion of infectious etiology. However, they planned to evaluate with labs, urinalysis, and chest x-ray. They would have a Computed Tomography (CT) of the head to rule out intracranial pathology. Opioid overdose was possible. They would try Narcan if the patient remained drowsy/hypnotic. The patient was admitted for seizure activity due to refractory hypoglycemia and possible opioid intoxication. 

The patient was given Narcan and became aggressive. He calmed down after a dose of Versed. He became hypoglycemic again with a reading of 27. Additional D50 was given followed by intravenous (IV) dextrose. His blood glucose levels ranged between 96-182. The IV dextrose was continued at a maintenance rate. A CT scan of the head and chest x-ray revealed no acute changes. The patient was admitted for further care. His blood glucose levels were monitored. Endocrinology was consulted. They recommended starting the patient on Novolin 70/30 35 units in the morning and 40 units at night. The patient had complaints of pain in the right leg. An x-ray of the right lower extremity identified no fractures. The patient's blood sugar levels were between 200-240 during the admission. Further dextrose containing fluids would be held off. The patient was educated on a diabetic diet by nutrition services. The patient was deemed hemodynamically stable and discharged. 

Per the Milliman Care Guidelines (MCG), clinical indications for admission for seizures is appropriate in patients who are hemodynamically unstable, have status epilepticus, have evidence of a brain disorder, when cardiac arrhythmias are of immediate concern, when there is altered mental status that is severe and persistent, when there is new focal neurological deficit, when there is metabolic disorder that persists despite observation care, or when there are recurrent seizures. The clinical documentation identified that the patient had a history of diabetes mellitus, heroin use, methadone dependence, hypertension, hyperlipidemia, and obesity. The documentation identified that the patient had a metabolic disorder that persisted despite observation care. There were also findings of abnormal troponin and abnormal heart rhythm. Additional close monitoring was needed secondary to the patient's drug use. These findings support a need for inpatient care based on guideline recommendations for persistent hypoglycemia despite observation care. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.