Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care.

The denial is overturned.

The patient has a history of diabetes mellitus. The patient reported a two day history of high blood sugars, urinary frequency, nausea, and vomiting. He was afebrile with sustained tachycardia greater than 110 beats per minute (bpm). The laboratory results demonstrated the following: Glucose 410 milligrams (mg) per deciliter (dl), carbon dioxide (CO2) - 8, anion gap - 34, ketonuria, and venous PH (potential of hydrogen) 7.08. The Renal Labs were: creatinine 1.45 with a glomerular filtration rate (GFR) down to 53. The patient was admitted inpatient (critical care) for treatment of diabetic ketoacidosis (DKA)/metabolic acidosis, and acute kidney injury. The patient received two liters of sodium chloride 0.9% bolus with continuous rate 200 cubic centimeter per hour (cc/hr), continuous insulin infusion, hourly point of care glucose monitoring, additional sliding scale insulin as needed and deep vein thrombosis (DVT) prophylaxis with Lovenox. The patient signed out of the hospital against medical advice from the critical care unit.

"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." (Gosmanov, A.R. et al.).

Commonly accepted criteria for diabetic ketoacidosis are blood glucose greater than 250 mg/dl, arterial pH less than 7.3, serum bicarbonate less than 15 mEq/l [milliequivalents per liter], and the presence of ketonemia or ketonuria. The normal anion gap is 12 mEq/l. Anion gap greater than 14-15 mEq/l indicates the presence of an increased anion gap metabolic acidosis.[17] Arterial pH may be normal or even raised if other types of metabolic or respiratory alkalosis coexist. Typical examples are vomiting or diuretic use.[18] Blood glucose may be normal or minimally elevated in patients with DKA (<300 mg/dl), where the underlying risk of hypoglycemia preexists, such as in patients with alcohol use disorder or patients receiving insulin or SGLT2 (class of prescription medicines that are FDA-approved for use with diet and exercise to lower blood sugar in adults with type 2 diabetes) inhibitors. 

Based on the medical facts from the available records, the health care plan did not act reasonably and with sound medical judgment or in the best interest of the patient, as the inpatient hospital admission would be considered medically necessary for this patient.   

Therefore, in this patient's clinical situation, the inpatient level of care was medically appropriate and necessary.
                                                    
The insurer's denial of coverage for inpatient level of care is overturned. Medical Necessity is substantiated.