Diagnosis: Pregestational diabetes
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female. She was admitted to the hospital at 36 3/7 weeks' gestation for a variety of presenting complaints, of which the most urgent and potentially risky was that her pregestational diabetes was out of control. In addition to this problem, she also complained of back pain, vomiting, palpitations, and decreased fetal movements.

Based on her history, she was felt to be noncompliant with her treatment regimen as outpatient. It is documented that she refused insulin treatment for her diabetes, and that she stated that her blood sugars ran in the 200s at home. Random blood sugar obtained was 154-148. At the time of presentation, she had a tachycardia to 118, blood pressure 111/61, temperature 37.2, and benign chest and abdominal physical exam. Her pulse came down to 91 without treatment. She received sliding scale insulin and fetal monitoring. The heart rate tracing, back pain, palpitations, and vomiting resolved within one day of admission, and it was felt that she was safe for discharge.

The facility contends that the admission level of care was medically necessary due to the fear of fetal compromise and that there was no feasible way to discharge the patient and cites MCG Obstetric and Gynecologic criteria. The health plan contends that the admission was not medically necessary, that the care was approved at observation level, and cites MCG 23rd edition.

None of the abnormalities noted at admission was life threatening to either mother or baby and all resolved within one day of admission without specific treatment. The diabetes was not sufficiently severe to merit admission unless the patient had failed outpatient treatment with intermittent insulin administration due to brittle diabetes and/or hypoglycemic episodes, and per the records the patient had refused this treatment and had no documentation of brittle diabetes or hypoglycemia. Therefore, the admission was not medically necessary, and the care could have been given at a lower level of care.