Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hyperglycemia

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

According to the medical records, this patient has a history of Type 2 Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), and Polysubstance abuse. The patient presented to the emergency department (ED) with polyuria, polydipsia, and headaches. He has a history of multiple ED admissions with hyperglycemia and was recently discharged on Insulin aspart and sitagliptin but never took the medication. The patient's Hemoglobin A1c (glycated hemoglobin) was 14%, finger stick was in the 400's, glucose was elevated in urinalysis (UA), and urine ketones were 40.

Laboratory results were as follow: pH (potential for hydrogen) 7.34, pCO2 (partial pressure of carbon dioxide) 49, pO2 (partial pressure of oxygen) 65, HCO3 (Bicarbonate) 26, Sodium 130, potassium (K) serum 4.5, Chloride 93, carbon dioxide (CO2) 22, Creatine 1.1, blood urea nitrogen (BUN) 11, Anion Gap 15, Glucose 426, Urine Glucose greater than (>)1000. He was admitted for hyperglycemia with polydipsia. Endocrinology services were consulted. His treatment plan included basal/bolus insulin and sliding scale; however, the patient refused finger sticks and insulin administration. The patient left against medical advice (AMA).

"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 of special situations such as DKA or HHS presentation in comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during the therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis. Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis." (Gosmanov, et al., 2018).

"When hyperglycemia is left untreated, it can lead to many serious life-threatening complications that include damage to the eye, kidneys, nerves, heart, and peripheral vascular system. Thus, it is vital to manage hyperglycemia effectively and efficiently to prevent complications of the disease and improve patient outcomes." (Mouri, M., & Badireddy, M. 2021).                                                          

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 inpatient admission services is substantiated.