Diagnosis: Type I diabetes mellitus
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission.
The denial is upheld.

The patient is an adult female, with a medical diagnosis of type I diabetes mellitus. She presented to the emergency department (ED) complaining of polyuria, polydipsia, fatigue, generalized malaise and nausea associated with hyperglycemia with blood glucose levels elevated to 200-400 milligrams per deciliter (mg/dL) for the previous three days. The patient reported to have run out of her long-acting insulin, Tresiba, four days prior and have been unable to fill it due to problems with her insurance coverage. As a result, she was forced to only use her short acting insulin Admelog.

Upon arrival, the patient was hypertensive with an elevated blood pressure of 146/100 millimeters of mercury (mmHg) and tachycardia, with a heart rate of 113 beats per minute. The patient's blood work indicated an elevated fasting sugar of 408 mg/dL (milligrams per deciliter), an elevated blood glucose of 387, decreased phosphorus of 2.2, and an elevated A1C of 10.5% (percent).

The patient was initially treated with a one-liter bolus of lactated ringers, potassium, subcutaneous Lantus 38 units, and subcutaneous Admelog three (3) units.

The patient was admitted with a diagnosis of hyperglycemia. The inpatient plan of care included serial blood work, tight glycemic control, continuation on Lantus 38 units at bedtime, Admelog five (5) units three times daily prior to meals with low dose insulin sliding scale, and an endocrinology consult. The patient was evaluated by endocrinology, and she was to be discharged on the long-acting insulin Basaglar 48 units at bedtime, as it was newly covered by her insurance.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.