Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic Ketoacidosis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned

The patient has a past medical history of asthma, diabetes, hypertension, and substance use, who presented to the emergency department with a concern for diabetic ketoacidosis with nausea, diarrhea, and abdominal pain. She was noted to have missed her insulin for the prior two days prior to presentation.
On presentation, she was afebrile with systolic blood pressures of 102-119, heart rates 77-93, respiratory rates 19-22, and oxygen saturations 96-100% on room air. The exam otherwise noted her to be yelling, alert and oriented with a normal abdominal exam and without other acute exam abnormalities. Labs resulted with a white blood cell count (WBC) of 22.3, hemoglobin (HGB) 13.3, platelets 352, sodium 141, potassium 5, blood urea nitrogen (BUN) 12, creatinine 1.09, bicarbonate level 10, glucose 570, anion gap 25, and total bilirubin 1.9 with the rest of her liver function tests within normal limits. The beta-hydroxybutyrate level also was so high it was unmeasurable and just reported at greater than [>] 4.0 (normal less than [<] 0.3). A venous blood gas noted significant acidosis with a potential of hydrogen (pH) of 7.17. A urinalysis showed so many ketones they were unmeasurable and reported as just > 160. Coronovirus disease 2019 (COVID-19) and influenza testing were negative. A chest x-ray showed no acute process. The patient was started on intravenous (IV) fluids and IV insulin in the emergency department. She was brought into the hospital with a concern for diabetic ketoacidosis (DKA) in the setting of synthetic cannabis or marijuana (K2) substance use and missing her insulin without any other identified triggers such as an infection for her DKA, and with plans for an overlapping insulin drip and subcutaneous insulin for 2 hours with initiation of her home insulin regimen, continuing IV fluids, and repeating a basic metabolic panel.
Overnight and the next day, the patient's acidosis gradually improved, though it was noted in the afternoon, the bicarbonate level was still low at 16. She remained hemodynamically stable. Her hyperglycemia resolved but then she developed hypoglycemia to 41 overnight requiring a dextrose push. She was encouraged to stay given her fluctuating blood glucoses but insisted on leaving against medical advice.
The issue under review is whether care at the inpatient level was medically necessary.

The inpatient level of care was medically necessary for this patient presenting with severe DKA, and subsequent critical hypoglycemia after her hyperglycemia had resolved.
This is a patient who presented with severe DKA as manifested by a pH of 7.17, beta hydroxybutyrate of >4, hyperglycemia >500, anion gap (AG) of 25, and ketonuria. Given the severity of her acidosis, she was at high risk for hypotension, organ dysfunction, electrolyte abnormalities and even death. She required intensive therapy with an insulin drip, IV fluids, and close electrolyte monitoring. She subsequently developed significant hypoglycemia requiring a dextrose push and continued to be at risk of severe hypoglycemia or hyperglycemia, with ongoing hospitalization recommended but the patient chose to leave against medical advice (AMA) instead. The patient had presented with DKA that was not subtle but rather severe with an AG of 25, pH 7.1, bicarbonate level as low as 8, ketonuria, and unmeasurable Beta hydroxybutyrate. The patient met Milliman Care Guidelines (MCG) for medical necessity for inpatient admission for DKA based on her very elevated anion Gap, Beta hydroxybutyrate level > 3, pH of 7.17, hyperglycemia, ketonemia, and bicarbonate level as low as 8. She presented with severe DKA, as noted above, with then significant hypoglycemia as low as 41 and required medical necessary care at the inpatient level of care. Although she left the hospital quickly (with it noted that she additionally left against medical advice (AMA)), the inpatient stay was medically necessary.