Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gestational Diabetes
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is partially overturned.

This patient is a Gravida 2, preterm 0, abortions 1 (G2P0A1) who presented at 34-0/7 weeks gestation by 16-week scan with gestational diabetes and reported vomiting.

The patient reported that they were vomiting all food and intake. They denied vaginal bleeding, leakage of fluid, contractions, headache, blurry vision, right upper quadrant (RUQ) pain or COVID-19 symptoms. The patient had a pregnancy complicated by gestational diabetes, history of myomectomy and obesity. The prior pregnancy history was noted for prior 16-week spontaneous abortion. The patient denied any smoking, alcohol, or illicit substance abuse. The review of systems was positive for vomiting.

The vital signs were normal with a blood pressure of 131/71, temperature of 97.5 degrees Celsius, pulse 104, respirations 19 and weight of 204 pounds (lbs.). Fetal heart tones were in the 170's with moderate variability, positive accelerations, and no decelerations. The cervix was closed, long, and posterior. The patient was admitted for terbutaline, betamethasone, intravenous (IV) hydration, and monitoring.

The patient was diagnosed with gestational diabetes and was started on insulin. The plan was made for finger sticks every 4 (Q4) hours and insulin on a sliding scale regimen. The patient underwent evaluation for gallstones by ultrasound and was ordered Reglan and Pepcid for vomiting. The patient was on 14 units of isophane insulin (NPH) at bedtime and 14 units of regular insulin before dinner. They were also on 38 units of isophane insulin (NPH) and 18 units of regular insulin 30 minutes prior to breakfast. A urinalysis was noted to be concerning for dehydration and possible infection.

The patient was now 34-3/7 weeks gestation and had normal exam and vital signs. The patient had no complaints. The patient's finger stick blood glucose (FSBG) fasting was 84-95. Fetal testing was reassuring and category I fetal tracing was noted. The patient's 2-hour post-prandial values were 110, 121, and 114 before discharge. The patient was discharged home with insulin-controlled diabetes. At issue is the medical necessity of the inpatient stay.

The requested health service/treatment of inpatient hospital admission is partially deemed medically necessary for this patient. Based upon a review of the medical records and the American College of Obstetricians and Gynecologists recommendations and Milliman Care Guidelines (MCG) Guidelines, the patient would meet medical necessity for admission to acute inpatient level of care on three out of four days of the hospital stay. The patient would not meet medical necessity for admission to acute inpatient level of care for the last two days given maternal diabetes, vomiting and administration of steroids for fetal benefit in the setting of maternal diabetes.

In this case, admission was found to be medically necessary for the first three days of the admission given maternal diabetes and severe vomiting evidenced by dehydration on urinalysis with need for steroids and then control of hyperglycemia in the setting of maternal betamethasone administration for fetal benefit. In this case, the patient had very poorly controlled diabetes when the steroids were given and given the admission status of dehydration and nausea with ongoing vomiting, the patient would meet medical necessity under the Milliman Care Guidelines (MCG) Guideline for Diabetes in this case. The patient was noted to have achieved control of diabetes on insulin after adjustments daily on the third day of the hospital stay and was eligible for discharge to home at that time given no further nausea and vomiting and stable status with reassuring fetal testing.

Thus, only half of the admission is medically necessary at the acute inpatient level of care. Discharge was safe after patient recovery and control on insulin.

The American College of Obstetrics & Gynecology recognizes the importance of tight blood glucose control when administering steroids to a patient with diabetes as seen in this case. Given the need for insulin for this control and the inability for the patient to reliably keep down food due to vomiting, it was unsafe to have this patient managed at a lower level of care than inpatient admission for the first half of the admission.