Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

According to the records the patient has a diagnosis of gastroparesis and non-specific abdominal pain. The patient presented to the Emergency Room (ER) with complaints of nausea, vomiting, abdominal pain and inability to tolerate oral intake. The patient has a medical history of type 1 diabetes. The patient's vitals showed a temperature of 99.1 Fahrenheit (F), heart rate of 102 and a blood pressure within defined limits. The patient's labs showed a glucose of 273, anion gap of 14.7, and bicarbonate of 21.3.

As stated in the Milliman Care Guidelines (MCG), inpatient admission is indicated for diabetes when diabetes is uncontrolled as indicated by diabetic ketoacidosis with acidosis (e.g., arterial pH less than 7.30, serum bicarbonate level less than 15) (1). Further, inpatient admission is indicated when there are severe signs or symptoms secondary to hyperglycemia indicated by 1 or more of the following: altered mental status, significant hypovolemia or dehydration, intractable nausea or vomiting or when management at other levels of care is not feasible because the condition was not adequately corrected with treatment at other levels of care.

As stated in the InterQual Guidelines (General Medical, Endocrine or Metabolic), inpatient admission is indicated for diabetes when there is diabetic ketoacidosis (DKA) with arterial blood gas test or venous blood gas pH less than 7.35 or bicarbonate less than 18, blood sugar greater than 500 and there is a need for intravenous (IV) insulin greater than or equal to two times in 24 hours or continuous or IV hydration greater than 125 milliliters/hours (mL/h) or 100 mL/h with age greater than or equal to 65, renal failure, heart failure (HF) (4).	  

"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" (2).

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (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" (1).

"Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration. It is a life-threatening complication of diabetes and is usually seen in patients with type-1 diabetes mellitus. Commonly accepted criteria for diabetic ketoacidosis are blood glucose greater than 250, arterial pH less than 7.3, serum bicarbonate less than 15, and the presence of ketonemia or ketonuria" (3).        

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 an inpatient admission is not substantiated.