Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemic Crisis. 
Treatment: Full Hospital Admission. 

The insurer denied coverage for full hospital admission. 

The denial is upheld. 

The patient is a male with a history of diabetes mellitus. The coverage request is for an inpatient stay for hyperglycemic crisis. The coverage was previously denied by the insurance carrier, this is an appeal. The coverage for inpatient admission was previously denied because it was deemed not medically necessary. 

The patient presented to the emergency room (ER) with complaints of a three-month history of increased thirst and urination. Labs showed glucose was 408, sodium was 129, anion gap was 14, beta-hydroxybutyrate was 4.92, serum osmolality was 305, pH (potential of hydrogen) was 7.34, and bicarbonate was 23. Mental status was normal. In the ER (emergency room), the patient was given an intravenous (IV) fluid bolus and 15 units of Lispro. He was admitted to Medicine with a hyperglycemic crisis. The patient was started on Lantus and sliding scale insulin and oral agents for diabetes were later added. The patient was educated on proper insulin administration and given diabetic teaching. He was discharged. 

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises' management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential special situations such as DKA or HHS presentation in the comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis.....While DKA is a state of near absolute insulinopenia, there is sufficient amount of insulin present in HHS to prevent lipolysis and ketogenesis but not adequate to cause glucose utilization (as it takes 1/10 as much insulin to suppress lipolysis as it does to stimulate glucose utilization)." (Gosmanov AR, et al.,)

Based on the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the full hospital stay was not medically necessary for this patient. The patient did not meet criteria for inpatient admission because he did not meet criteria for diabetic ketoacidosis requiring inpatient management (no evidence of acidosis or low bicarbonate), he did not meet criteria for hyperglycemic hyperosmolar state (glucose was <600, osmolality was not sufficiently elevated and no neurologic dysfunction), and he did not meet criteria for hyperglycemia complicated by persistent/severe altered mental status, dehydration, vomiting or electrolyte abnormality. The care could have been accomplished at an observational level of care. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.