Diagnosis: Cardiac/Circulatory Problems. Treatment: Inpatient hospital The insurer denied inpatient hospital admission for medical necessity. The denial was upheld. The patient is a male who initially presented to an urgent care and was found to have hyperglycemia. He was sent to the hospital. His pertinent history included diabetes mellitus, renal cancer with metastases to the lungs and thoracic lymph nodes undergoing active chemotherapy and prednisone use, and chronic kidney disease. Upon arrival the patient was afebrile, hemodynamically stable, and without hypoxia. His initial examination documented the patient as alert and oriented. Serology was obtained and revealed a serum glucose of 257, Anion gap of 10, creatinine (Cr) was 1.6 (improved from baseline), white blood cell count (WBC) was 15.7, and lactic acid was 2.6. His electrocardiogram (EKG) revealed sinus bradycardia without acute ischemic changes or conduction abnormalities. Multiple tests and labs were done and pertinent for a negative troponin and clear chest radiography. Due to persistent asymptomatic sinus bradycardia of unknown etiology, the plan was to admit to telemetry overnight for further evaluation. His serum glucose returned at 257. Endocrinology consultation was obtained whom noted a heart rate of 64 and a morning fingerstick glucose of 69. They had an impression of steroid-induced hyperglycemia and recommended subcutaneous insulin. Recommendations were to hold metoprolol and continue telemetry. Cardiology consultation was obtained whom had an impression of sinus bradycardia possibly due to high dose steroids. The serum glucose remained in appropriate ranges. Treatment plan remained unchanged. The attending physician also noted serum glucose control and felt the patient was medically stable for discharge. At issue is the inpatient stay for medical necessity. The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient stay is not medically necessary for this patient. Based on the clinical documentation provided, evidence-based literature and standards of care, the inpatient level of care was not indicated as medically necessary for the entire admission. Savage et al. note that diabetic ketoacidosis is defined by the biochemical triad of ketonemia, hyperglycemia and acidemia. It remains a life-threatening condition despite improvements in diabetes care. In this particular case, these criteria were not met. Regarding the bradycardia, Semlka, et al. note that treatment of sick sinus syndrome includes removing extrinsic factors, when possible, and pacemaker placement. Pacemakers do not reduce mortality, but they can decrease symptoms and improve quality of life.[2] In this particular situation, expert consultation with a cardiologist was obtained whom had an impression of clinically insignificant sinus bradycardia. Thus, pacemaker implantation was not indicated. Therefore, the requested treatment of inpatient stay was not medically necessary.

1) Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JA, Courtney CH, HiltonL, Dyer PH, Hamersley MS, Joint British Diabetes Societies. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabetic Medicine. 2011 May;28(5):508-15. 2) Semelka M, Gera J, Usman S. Sick sinus syndrome: a review. American family physician. 2013 May 15;87(10). 3) Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation. 2019 Aug 20;140(8):e333-81.