Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Ketoacidosis (DKA).

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of chronic pancreatitis secondary to elevated triglycerides and secondary diabetes who presented to the emergency room (ER) with complaints of abdominal pain and vomiting typical of his usual pancreatitis. His labs showed elevated blood sugar (BS) of 332 with and Anion gap (AG) of 25, and elevated lipase. Venous Blood gases (VBG) also showed a PH (potential hydrogen) of 7, 57, partial pressure carbon dioxide (PCO2) of 20, partial pressure oxygen (Po2) of <33 and bicarbonate (HCO3) of 18. He was subsequently admitted with diagnoses of Abdominal Pain and diabetic ketoacidosis (DKA). The computed tomography (CT) scan in the ER failed to show acute pancreatitis but showed evidence suggestive of interval development of Schmorl's nodes versus osteomyelitis. Additional admitting diagnoses included Metabolic acidosis and Respiratory Alkalosis. Hospital stay was relatively benign, patient had quick response to the insulin drip which was discontinued after AG was corrected and patient was placed on 20 units Levemir and Sliding scale coverage with good control of his BS. He was subsequently discharged with outpatient follow up with Endocrinology.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.  The inpatient admission is not considered medically necessary for this patient.

Dhatariya, K. K., et al., "Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children."
    
Based on review of provided records, the patient has a history of chronic pain for which he was on Suboxone, CT did not show any evidence of Acute Pancreatitis, the findings of interval development of Schmorl's nodes was incidental and patient had no evidence to support Osteomyelitis as such shown by both the ER and Admitting Physician notes, the primary reason for admission was DKA with the associated electrolyte abnormalities. The patient had a quick response to the administered insulin and fluid treatments with quick correction of the Anion gap and BS control was quickly attained with a relatively modest dose of Levemir and Sliding scale coverage. Care and treatment of the patient could have been safely and appropriately managed at a lower level of care, such as observational.

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