Diagnosis: Diabetes
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient is a male. The patient presented with a frontal headache and abdominal pain. Blood glucose was found to be 607. The patient was taken to the emergency room. The patient had a history of polyuria and polydipsia for several weeks. The patient has a family history of type I diabetes and brother and sister.

In the emergency room, the patient had a glucose of 479. He was ketone positive. He was given intravenous normal saline boluses. The patient was diagnosed with new onset type I diabetes. He was started on Levemir and NovoLog using an insulin to carbohydrate ratio and an insulin sensitivity factor. Hemoglobin A1C (glycated hemoglobin) was found to be 11.1%. The patient received new onset diabetes education.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components [1, 2].

Practice patterns differ depending on the availability of educators etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the US [3] that treat new onset type 1 diabetes admit their patients. According to the ADA statement on treatment of type 1 diabetes [4], hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education." That is not the case for type 2 diabetes. Indications for admission for new onset type 2 diabetes are more stringent and dependent upon the presence of symptoms such as ketosis, dehydration, hyperosmolarity, vomiting and inability to maintain hydration or severe metabolic/electrolyte abnormalities.

In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a two to three day admission to the hospital [5-8].

This patient had new onset type I diabetes and required all aspects of diabetes education in addition to determination of his insulin regimen. The patient is of an age where he should learn how to self-inject and check blood glucose. The duration of the admission was appropriate for complete diabetes education. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.