Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient is an adult who presented to the emergency department (ED) complaining of abdominal pain and persistent nausea and vomiting with inability to tolerate any oral intake for two days duration. The patient's medical history was significant for insulin dependent diabetes mellitus, gastroparesis, Hashimoto's thyroiditis, and erosive gastritis. The patient's bedside glucose in the emergency room revealed a reading of 414 with active dry heaving and reported a 10 out of 10 for abdominal pain. Work-up in the ED revealed a Sodium level of 140, Potassium at 3.6, Blood urea nitrogen of 12, Creatinine 1.11, Albumin 3.7 and Anion gap of 22 with a moderate amount of acetone. Recheck of her blood glucose was 432, white blood cell count was 14.4. A venous blood gas (VBG) revealed a potential hydrogen (pH) of 7.47, and she had 3+ ketones noted in her urine. The patient was started on intravenous (IV) fluids, Zofran and Toradol with sliding scale insulin drip supplementation. The patient was admitted to the intensive care unit (ICU) for close monitoring, further care and treatment of hyperglycemia, hypokalemia and hemodynamic instability. Medical record documentation of the patient hospital course shows that the patient was in the ICU for four days before being stable enough for transfer to the medical-surgical floor. At that time, she was tolerating oral fluids, her diet was advanced, and medications were changed to oral. Her nausea and vomiting subsided, and she continued to remain hemodynamically stable with the correction of her electrolytes. She was discharged to home the following day, with instruction to follow up with her primary care physician and endocrinologist in one week. She had supplementation of potassium, magnesium as well as sodium throughout this hospital course all due to severe diabetic ketoacidosis (DKA).

The patient met some of the diagnostic criteria for DKA based on the American Diabetes Association (ADA) and hospital admission guidelines. The patient's blood glucose was greater than 250 milligrams per deciliter (mg/dl), (greater than 13.9 millimoles per liter (mmol/L)) with an arterial pH less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L) and had ketonuria and/or ketonemia. Specifically, the patient's blood glucose 432 anion gap was 22 and she had moderate ketones. The pH may not be as reliable as this was a venous sample but overall, the patient's presentation is compatible with acute DKA.      

On review of the documentation, it was found that this patient is diagnosed with uncontrolled insulin dependent diabetes (probable type 1) with an Glycated hemoglobin (A1C) of 9.4%. The patient presented to the ED with abdominal pain and vomiting which is a common symptom of DKA. She was admitted to the ICU with a diagnosis of DKA and was placed on an insulin drip. The patient was treated with IV insulin, IV fluids, Toradol and Zofran. As previously stated, the patient met diagnostic criteria for DKA based on ADA and hospital admission guidelines.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.