Appeal type: Medical necessity
Decision: Overturned

Diagnosis: DKA (diabetic ketoacidosis)

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

According to the medical records, the patient is a female with a history of chronic kidney disease (CKD) stage 3, diabetic retinopathy, type 1 diabetes mellitus (DM) with insulin pump, diabetic ketoacidosis (DKA), hypertension, gastroparesis, depression with anxiety, and hyperemesis. 

The patient presented to the emergency department (ED) with persistent vomiting and subsequent epigastric pain times 1 day. She was unable to hold food or liquids down. Vomiting was associated with epigastric pain, non-radiating, and loose stools times 1 day. The ED course included 1000 ml (milliliter) Sodium Chloride 0.9% (percent), Benadryl Injection 25 mg (milligram), Pepcid injection, Hydralazine 20 mg injection, regular insulin 10 units, Ondansetron 4 mg times 2, and prochlorperazine injection 10 mg. Laboratory results were carbon dioxide (CO2) 16 mmol/L (millimoles per liter), blood urea nitrogen (BUN) 72 mg/dL, Creatinine 6.10 mg/dL, Calcium 7.5 mg/dL (milligrams per deciliter), and anion gap 16 mEq/L (milliequivalent per liter). The patient was admitted for DKA (diabetic ketoacidosis) without coma associated with type 1 DM (diabetes mellitus), acute kidney disease (AKI) on CKD stage 3 and started on insulin drip at 8 ml/hour (milliliters per hour) as per DKA protocol, insulin regular 10 units, and Glucose is 634 mg/dL. The patient was evaluated by Endocrinology and Nephrology. She was admitted for management of DKA without coma. She 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, A.R. et al. 2018)

Clinically, the patient had persistent vomiting, signs of dehydration and AKI from dehydration. The dehydration originated from vomiting due to severe hyperglycemic emergency specifically, DKA. The patient met diagnostic criteria for DKA, specifically her blood glucose was 630 with a low CO2 or bicarbonate of 16, anion gap of 16 and with positive serum and urine ketones. Therefore, the request for inpatient hospital admission is considered medically necessary for this patient.

The health care plan did not 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 overturned. Medical Necessity is substantiated.