Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Diabetes.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay.
The health plan's determination is overturned.

The patient is a male with hypertension (HTN), diabetes mellitus type 2 (DM2), hyperlipidemia, coronary artery disease (CAD), and recent cellulitis treated with Clindamycin who presented with worsening nausea, vomiting, and abdominal pain for the prior 3 days.

On admission, his temperature was 98.1F., with a blood pressure (BP) of 198/90 millimeters of mercury (mmHg), a heart rate (HR) of 96/minute, a respiratory rate (RR) of 20/minute, and an oxygen saturation of 95% on room air (RA). He was in distress from the abdominal pain. His lungs were clear, abdomen was soft, and he was alert and oriented. Labs resulted in a white blood cell count (WBC) of 14.8, a sodium of 131, a bicarb of 16 with an anion gap of 20, a blood urea nitrogen (BUN)/creatinine was 22/0.93, a bilirubin of 1.4, a lipase of 24, a troponin of < 0.01, and a beta hydroxybutyrate of 4.78. A computed tomography (CT) of the abdomen/pelvis found a fatty liver, no pancreatitis, likely gastritis and proctitis. A chest x-ray (CXR) found low lung volumes, no acute disease.

The patient was diagnosed with severe diabetic ketoacidosis (DKA) likely from Empagliflozin and was started on as needed (PRN) Hydromorphone for pain, insulin drip, intravenous (IV) fluids, frequent electrolyte monitoring. 

The next day, the patient remained nauseated; his sodium was 132, the bicarb was up to 23 (gap down to 10). The insulin drip was weaned off and insulin Glargine was started. Gastroenterology was consulted for gastritis and proctitis; they saw the patient, noted the abnormal CT, and planned for an endoscopy.

The next day, an esophagogastroduodenoscopy (EGD) found gastritis; a flex-sigmoidoscopy found no evidence of proctitis.

Later he was seen by cardiology for chest/abdominal pain and positive troponin (0.07), and they recommended routine CAD treatment (anti-platelet treatment, statin, beta-blocker) but saw no active issues. The patient was feeling better, with a repeat sodium of 133, a bicarb of 22, and glucose levels 140s-190s.

At issue is the medical necessity for the inpatient stay.

The health plan's determination is overturned, in whole.

Yes. An inpatient stay was medically necessary.
The patient presented with severe abdominal pain, nausea, and vomiting and was found to be in DKA. He was acidemic and had severe gastrointestinal (GI) symptoms and was unable to tolerate an oral intake. As such, an insulin drip was needed to manage his hyperglycemia and ketoacidosis, and this must be done in an inpatient setting for close monitoring, frequent labs, fingersticks, electrolyte repletion, and cautious fluid resuscitation for hypovolemia. This cannot be done in an outpatient setting. In addition, there was concern for acute gastrointestinal pathology that could be contributing to DKA, and he was started on antibiotics and was seen by gastroenterology with an endoscopy performed. The concern for acute pathology and the need for an expedited evaluation and management also could not be done on an outpatient basis. Finally, his elevated troponin, although ultimately not felt to be an acute process by cardiology, speaks to more severe disease, the need for close monitoring to ensure there is no active cardiac disease, and a higher risk of a worse outcome. Given all of this, an inpatient admission was needed for close monitoring and inpatient only treatments.