Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient is an adult with a medical  history of Type two (II) diabetes mellitus, hypertension, diabetic neuropathy, chronic back pain, major depressive disorder, anxiety disorder, and hyperlipidemia, who presented via ambulance to the Emergency Department (ED) for an emergency evaluation, due to wound to the left great toe, persistent vomiting, and hyperglycemia with an elevated blood sugar of 510 milligrams per deciliter (mg/dl) by medics. The patient's visiting nurse noticed the wound to his left great toe looked worse that day. The patient reported six episodes of emesis that day associated with polyuria, polydipsia, and diffuse abdominal pain. Triage vital signs were temperature 97.1 degrees Fahrenheit (F), heart rate 130 beats per minute (bpm), respiratory rate (RR) 20 breaths per minute, pulse oximetry 95% on room air (RA) and blood pressure (BP)132/91 millimeters of mercury (mm/hg). On examination, the patient appeared tachycardic, had dry mucous membranes, and had an open wound to his left great toe with warmth and swelling. Initial laboratory studies were remarkable for elevated glucose of 465, elevated white blood count (WBC) of 13.2, elevated neutrophil percentage (left shift) of 78.8%, venous blood pH of 7.39, venous blood partial pressure of carbon dioxide (pCO2) of 42 mmHg, low sodium level of 133 millimoles per liter (mmol/L), elevated anion gap of 13.6 mmol/L, elevated urine glucose of >1000, and positive urine ketones. Chest radiograph demonstrated no pneumonia. A left foot radiograph demonstrated soft tissue welling, no fracture or dislocation, no radiographic evidence of osteomyelitis, and a talar break. A computed tomography (CT) of the abdomen and pelvis demonstrated no evidence of acute appendicitis, diverticulitis, or mechanical bowel obstruction. The CT also showed hepatomegaly with moderate diffuse fat deposition. In the emergency department, the patient was administered normal saline one liter (L) intravenous (IV) fluid bolus three times (3x), Zofran four (4) milligrams (mg) intravenously, insulin eight (8) units subcutaneously, and Vancomycin intravenously. 

The patient did not meet diagnostic criteria guidelines for diabetic ketoacidosis (DKA) . The patient's blood glucose (BG) was greater than 250 milligrams per deciliter (mg/dl), (greater than 13.9 millimoles per liter (mmol/L)) and the patient did have ketonuria and/or ketonemia, but the patient did not have an arterial potential hydrogen (pH) less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L).
As stated in the Milliman Care Guidelines (MCG), inpatient admission is indicated for uncontrolled diabetes by BOTH of the following:
Diabetic ketoacidosis as indicated by ALL of the following:
Plasma glucose greater than 250 mg/dL (13.88 mmol/L) (MET)
Acidosis (e.g., arterial pH less than 7.30, serum bicarbonate level less than 15 milliequivalents per liter (mEq/L) (NOT MET)
Moderate ketonuria or ketonemia (MET). 
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.