Diagnosis: Diabetes Mellitus
Treatment: Inpatient Hospital

Summary: This patient with a past medical history of diabetes mellitus, obesity and asthma was seen in the Emergency Department (ED) with complaints of right ear pain for three days and nasal congestion with yellow mucus and scant blood for one day. The patient had a recent sick contact one week prior to presentation. The patient was not taking any diabetes medication due to lack of insurance. The patient stated that she had been monitoring her blood sugar through diet and exercise. The patient had not checked her blood sugar since running out of insulin. The patient noted that she has had diabetic ketoacidosis in the past when first diagnosed. The patient noted an intentional 134 pound weight loss in one year. The patient's blood sugar in the ED was high. The patient was given intravenous (IV) fluids and insulin and was admitted for further evaluation and management. The patient was started on Lantus and Lispro. The patient's blood sugars improved, and the patient was discharged with 70/30 insulin.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

The medical literature indicates that inpatient admission is indicated for patients with diabetes if there is evidence of diabetic ketoacidosis that requires inpatient management as indicated by hyperglycemia with a plasma glucose greater than 200 mg/DL, ketonuria or ketonemia with a serum beta hydroxybutyrate greater than 3, acidosis with an arterial or venous pH less than 7.3. Inpatient care may also be indicated for patients with hyperglycemic hyperosmolar state if there is evidence of plasma glucose greater than 600 mg/DL with serum osmolality greater than 320 and neurologic dysfunction. The documentation indicated that the patient was seen for ear pain. The patient was noted to have glucose greater than 530 and an HbA1c of 16.9. The patient's venous pH was 7.30. However, there was no indication that the patient had ketonuria or ketonemia with a serum beta hydroxybutyrate greater than 3. The patient's arterial or venous pH was not less than 7.30. There was no indication the patient had a serum osmolality greater than 320 and there was no evidence of neurologic dysfunction. Therefore, the patient's condition was appropriate for level of observational care rather than inpatient level care. The medical necessity is not substantiated.