Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional - Diabetes
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a female with diabetes and poor compliance who presented to the hospital with hyperglycemia and multiple other complaints. She has an intravenous (IV) drug abuse active history and reported running out of insulin for the past week. She denied nausea or vomiting. She was hyperglycemic in the emergency department (ED) with a glucose of 528, elevated anion gap, and acetone-positive status. She is currently on Suboxone.
The temperature was 36.8 Celsius (C), with a heart rate of 77 beats per minute (bpm), and a blood pressure of 156/78 millimeters of mercury (mmHg). On exam, she appeared oriented, with no acute distress. The cardiopulmonary exam was stable. The abdomen was soft, nontender, and nondistended; neurologically, the patient was intact.
The rest of the laboratory studies reveal sodium of 132, a bicarbonate of 17, and an anion gap calculated at 21. A venous blood gas showed a potential hydrogen (pH) of 7.21. The white blood cell count was normal. COVID-19 and influenza testing were unremarkable. A urinalysis showed a significant amount of ketones but no urinary tract infection (UTI).
The patient was admitted to the hospital with diabetic ketoacidosis (DKA), was given a 2-liter (L) bolus of lactated Ringer's in the ED, and was started on continuous infusion of IV fluids and insulin drip per DKA protocol. Furthermore, the patient complained of an abscess of the skin on her back, which was drained in the ED, and the patient was started on empiric antibiotic therapy.
Overnight, the patient did well with IV fluids and insulin and was transitioned to subcutaneous long-acting and prandial insulin by morning. Her diet was advanced, which she tolerated without difficulty. The back abscess improved and continued to drain, but she showed no signs of systemic infection. The medical team felt she was appropriate for discharge and released her with prescriptions for insulin. She was also given doxycycline for the treatment of the cutaneous abscess.
At issue is the medical necessity of the inpatient hospital stay.
The health plan's determination of medical necessity is upheld in whole.
the requested health service/treatment of inpatient emergency admission was not medically necessary for this patient. Based on the provided documentation, the patient had signs of DKA, which rapidly improved. There was no evidence of persistent hyperglycemia, severe electrolyte derangements, or persistently elevated anion gap that required ongoing treatment with IV fluids and insulin drip. The patient was rapidly transitioned to subcutaneous insulin. The primary cause for the DKA was noncompliance with insulin therapy. There was no clear evidence that the small abscess on the patient's back produced any systemic symptoms. After incision and drainage, the abscess resolved, and the patient was converted to oral therapy and discharged home. Based on these findings, the inpatient criteria were not satisfied.