Diagnosis: Type 2 diabetes mellitus.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is overturned.

This is a male patient with a history of hypertension (HTN), hyperlipidemia, and type 2 diabetes mellitus. He was seen in the Emergency Room (ER) for fatigue and hyperglycemia. His blood sugar was documented to be 1181 milligrams per deciliter (mg/dL). The patient's hemoglobin A1c (HbA1c) test result was 18%. Ketones were noted in his urine. In the ER, he was started on fluids and an insulin drip. He was noted to have an elevated anion gap and acute renal insufficiency (Creatinine- 4.0). He was counseled on diabetes management and discharged after inpatient care and management.

Per Kodner, C. et al. (2017), "Uncontrolled blood glucose levels in hospitalized patients with diabetes are associated with potential harms such as deleterious effects on wound healing, increased risk of infection, and delays in surgical procedures or discharge from the hospital."

Per Corsino, L. (2017), patients who are "hospitalized with a diagnosis of diabetes stay in the hospital for longer than those without a diagnosis of diabetes admitted for the same condition."

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient had renal insufficiency and ketones in his urine. Admission was warranted.

The full hospital admission is considered medically necessary for this patient. The admission was necessary. He was found to be in renal failure and had ketones in his urine. He also had a blood glucose level of 1181 mg/dL. He needed fluids and counseling.

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