Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uncontrolled Diabetes. 

Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

According to the medical records, the patient is female with a history of obesity, migraines, diabetes, fibromyalgia, and deep vein thrombosis (DVT). She presented to the emergency room (ER) with complaints of possible diabetic ketoacidosis (DKA). Blood glucose level was significantly elevated. The patient reported fatigue, shortness of breath (SOB) on exertion, and chest discomfort. Troponin was negative. Imaging was negative for pulmonary embolism (PE). On initial presentation, the patient was tachycardic (pulse of 128 beats per minute). On examination, the patient appeared to be in acute distress. Laboratory studies were remarkable for leukocytosis (white blood cell count of 16.3 x 109/L [liters]), microcytic anemia (hemoglobin 9.2 g/dl (grams per deciliter) with mean corpuscular volume [MCV] 61 fl [fluid ounce]), hyponatremia (sodium 131 mEq/L [milliequivalents per litre]), severe hyperglycemia (glucose 395 mg/dl (milligrams per deciliter), anion-gap metabolic acidosis (bicarbonate 18 mEq/L with anion-gap of 20 mEq/L), elevated D-dimer (264 ng/ml [nanogram per deciliter]), lactic acidosis (lactate 2.6 mmol/L [millimoles per liter]), and urinalysis with elevated specific gravity >1.030, protein, glucose, ketones, leukocytes, and blood. She was given IV [intravenous] fluids, duo-nebulizers, Levaquin, and Diflucan. The patient was admitted with and a suspected urinary tract infection (UTI). She was started on bilevel positive airway pressure (BIPAP) support for suspected obstructive sleep apnea (OSA). Endocrinology recommended starting the patient on 70/30 insulin. The patient's condition was stabilized, and she was discharged. 

The patient failed to meet diagnostic criteria for DKA based on American Diabetes Association (ADA) and hospital admission guidelines: 
 
Blood glucose (BG) greater than 250 mg/dl, (greater than 13.9 mmol/L with: 

1) Arterial pH (potential of hydrogen) less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L) and 

2) Ketonuria and/or ketonemia. 
 
Specifically, her BG was 395 with a normal carbon dioxide (Co2) or bicarbonate of 18, anion gap of 20 and with weakly positive ketones. 
 
"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in patients with diabetes. Although DKA and HHS are often discussed as separate entities, they represent points along a spectrum of hyperglycemic emergencies due to poorly controlled diabetes. Both DKA and HHS can occur in patients with type 1 and type 2 diabetes; however, DKA is more common in young people with type 1 diabetes (T1D) and HHS is more frequently reported in adult and elderly patients with type 2 diabetes (T2D). In many patients, features of the two disorders with ketoacidosis and hyperosmolality may also co-exist. The frequency of DKA has increased by 30% (percent) during the past decade, with more than 140,000 hospital admissions per year in the United States." (Fayfman, M. et al. 2017) 
 
The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

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