Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild diabetic ketoacidosis (DKA)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld.

The patient is a male with a past medical history significant for type I diabetes mellitus, gastroparesis, and tetrahydrocannabinol (THC) use who presented to the hospital with complaints of nausea and vomiting for one day. The patient described multiple episodes of non-bloody, non-bilious vomitus. This was associated with abdominal and back pain.
It was reported that the patient had frequent admissions for diabetic ketoacidosis (DKA) within the last 6 months before the day of the presentation.
The review of systems was positive for appetite change, abdominal pain, nausea, vomiting, arthralgias, and back pain. The rest of the review of systems was negative.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender, and non-distended. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that potential hydrogen (pH) was 7.42, partial pressure of carbon dioxide (PCO2) was 43, and bicarbonate was 28.
White blood cell count was 10.2, hemoglobin 13.6, hematocrit 42.8, and platelets 127. Sodium was 138, potassium 5.3, chloride 101, bicarbonate (HCO3) 19, blood urea nitrogen (BUN) 16, creatinine 1.18, and magnesium 2.2. Lactic acid 4.5.
The patient was admitted to the hospital with mixed metabolic acidosis/alkalosis, mild DKA, versus starvation ketosis and intractable vomiting.
The patient received treatment with intravenous fluids and antiemetics.
As a result of the treatment provided in the hospital, the patient's clinical condition improved. The diet was restarted, and the patient tolerated it. The patient was cleared for discharge.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient. The patient presented to the hospital with complaints of nausea and vomiting for one day. The patient had lactic acidosis, which was most likely the result of dehydration.
However, the patient's condition was not associated with severe hyperglycemia, persistent acidosis, hemodynamic instability, altered mental status, severe or profound dehydration, or severe or profound vomiting. The patient's nausea and vomiting significantly improved within a short period of time. Furthermore, there were no indications that the patient had any concomitant condition requiring admission at the acute inpatient level of care.
The patient's hospital stay was relatively short. During the period of the hospitalization, the patient's clinical condition significantly improved. The symptoms that brought the patient to the hospital improved within a short period of time. Neither results of the laboratory studies nor diagnostic tests revealed severe underlying medical problems requiring admission at the acute inpatient level of care.
The patient could have been managed at a lower level of care status.