Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient presented to the emergency room (ER) with complaints of blurry vision and abdominal pain. Glucose level was in the 330's milligrams per deciliter (mg/dl). The patient is compliant with her diabetes medication regimen. Glucose level in the ER was 388 mg/dl. Vital Signs noted for temperature of 37.1degrees Centigrade, heart rate 95, blood pressure (BP) of 140/87, respiration of 17/minute, oxygen saturation of 98 percent (%). Labs were noted as sodium (Na) of 131, Blood urea nitrogen (BUN) 11, carbon dioxide (CO2) 15, Anion gap 16, pH of 7.29 and Total protein serum 9.8. The patient was given 10 mg of intravenous (IV) insulin and IV crystalloid fluids. The patient was admitted for care. The patient was started on 10 units of Detemir at night (HS) and pre-prandial Lispro 3 units three times a day (TID). Sliding scale coverage was provided. Imaging of the head was negative. The patient was discharged after a period of medical stability.

The patient met diagnostic criteria for diabetic ketoacidosis (DKA) based on the American Diabetes Association (ADA) and hospital admission guidelines. The patient's blood glucose (BG) was greater than 250 mg/dl, [greater than 13.9 millimoles per liter (mmol/L)] with 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). Specifically, on the day of presentation, the patient's BG was 388. She had a low CO2 or bicarbonate of 15, pH of 7.29 and an anion gap of 16. The patient also had elevated urine ketones and the patient required an insulin drip.

"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)

"DKA and 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% during the past decade, with more than 140,000 hospital admissions per year in the United States." (Fayfman, M. et al. 2017)

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.