Diagnosis: Diabetes
Treatment: Inpatient hospital admission

The health plan denied: Inpatient hospital admission
The determination is: Overturned

The patient is a male with a past medical history of diabetes mellitus type 2 (DM2), gastroesophageal reflux disease (GERD), and human immunodeficiency virus (HIV) who was admitted with complaints of (c/o) having his insulin stolen and weakness. His vital signs and physical exam were unremarkable. His lab work was notable for a blood glucose of 955, positive respiratory syncytial virus (RSV), a potential hydrogen (pH) of 7.30, and calculated serum osmolality of 297. His imaging studies and chest x-ray (CXR) showed no acute pathology. The patient was diagnosed with severe hyperglycemia and hyperglycemic hyperosmolar state with elevated serum osmolality and was treated with intravenous fluids (IVF), Lantus, and Humalog. The patient was discharged in stable condition.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is overturned, in whole.
The requested health service/treatment of inpatient level of care was medically necessary. This patient presented to the emergency department (ED) with weakness associated with medication non-adherence due to stolen medications. He was found to have profound hyperglycemia and diagnosed with hyperglycemic hyperosmolar state with borderline pH, and neurologic dysfunction (weakness). For patients with hyperglycemic hyperosmolar state, all but the mildest cases should be admitted to the hospital for close clinical monitoring due to rapid shifts in fluids and electrolytes and potential for deterioration in mental status and arrhythmias, in addition to frequent serial labs. Additionally, this patient's clinical status was complicated by the presence of immuno-suppression due to both uncontrolled diabetes and HIV with concomitant RSV. Overall, this patient could not have been safely treated and monitored at an alternative level of care.