Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female who presented with epigastric pain and nausea. History included diabetes mellitus type 1 on insulin pump, gastroesophageal reflux disease, and right breast cancer status/post (s/p) bilateral mastectomy. Initial serology revealed a white blood cell (WBC) 21.2, hemoglobin (Hgb) 13.5, platelets (Plt) 253, glucose (Glu) 365, carbon dioxide (CO2) 9.5, blood urea nitrogen (BUN) 37, creatinine (Cr) 0.92, Lipase 5, and calculated anion gap 24. Urinalysis revealed 20 ketones. Chest radiograph was unremarkable. Computed tomography (CT) abdomen/pelvis noted fatty infiltration of the liver and colonic diverticulosis without diverticulitis, cholecystitis, or pancreatitis. A diagnosis of diabetic ketoacidosis was provided, and an insulin infusion was initiated. The patient was admitted thereafter. Later in the evening, the acidosis resolved, and the anion gap was closed. The insulin infusion was discontinued and transitioned to subcutaneous insulin. Endocrinology consultation was obtained who attempted to resume the patient's home insulin pump, but it was malfunctioning. Diet was advanced and tolerated. Glycemic control was achieved with a subcutaneous insulin regimen. The new insulin pump was initiated, and the patient was deemed medically stable for discharge.

The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient. The patient had a history of diabetes mellitus type 1 on an insulin pump who presented with abdominal pain and nausea. Initial evaluation revealed a Glu 365, CO2 9.5, Anion gap 24, and 20 ketones in the urine. A diagnosis of diabetic ketoacidosis was made, and an insulin infusion was initiated. The anion gap was closed with resolution of acidosis and thus a transition to subcutaneous insulin was successfully performed.

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. The diagnostic criteria for diabetic ketoacidosis are ketonemia 3 millimoles per liter (mmol/l) and/or significant ketonuria (more than 2+ on standard urine sticks); blood glucose over 11 mmol/l (greater than [>] 180 milligrams per deciliter [mg/dl]) or known diabetes mellitus; venous bicarbonate (bicarbonate [HCO3] -) below 15 mmol/l and/or venous pH less than 7.3. [1] In this particular situation, the criteria was met.

Westerberg notes that diabetic ketoacidosis (DKA) is characterized by a serum glucose level greater than 250 milligrams (mg) per deciliter (dL), a pH less than 7.3, a serum bicarbonate level less than 18 milliequivalents (mEq) per liter (L), an elevated serum ketone level, and dehydration. DKA has a case fatality rate of 1 to 5 percent. Although the highest rate of mortality is in older adults and persons with comorbid conditions, DKA is the leading cause of death in persons younger than 24 years with diabetes, most often because of cerebral edema. [2] In this particular situation, the criteria was again met.

Moreover, clinical indications for admission to inpatient care were met. The patient had hyperglycemia, ketonuria, acidosis, and a serum bicarbonate less than 15 mEq/L with an anion gap greater than 12. [3] Evaluation and management could not have safely been performed at a lower level of care.