Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis.

Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is overturned.
 

The patient is an adult with a medical history of Type 1 diabetes mellitus and bipolar disorder. The patient presented to the Emergency Department (ED) for high blood pressure, anxiety, and shakiness. Vital signs showed the heart rate was between 108-131 beats per minute, and the blood pressure was 167/88 millimeters of mercury (mmHg). The glucose was critically elevated at 746 milligrams per deciliter (mg/dl), blood urea nitrogen (BUN)/creatinine was 21.7/1.43 (elevated above baseline), sodium 131, chloride 91, the total CO2 (carbon dioxide) was 16 with an elevated anion gap of 25, and a positive serum acetone. The venous blood gas showed a critically low pH (potential of hydrogen) of 7.28. The white blood cell count was 10.9 with a left shift. In the ED, he received intravenous (IV) fluids and IV insulin. The admitting physician indicated diabetic ketoacidosis (DKA) and bipolar disorder. The admitting orders included admission to the Intensive Care Unit (ICU), 10 units IV regular insulin, then IV insulin drip, IV lactated Ringer's, diabetic ketoacidosis (DKA) protocol, fingerstick every hour, follow-up labs, psychiatry, and case management consults. He was tachycardic throughout the day. Follow-up labs showed the potassium was low at 2.9, calcium critically low at 6.8, and magnesium low at 1.4. He received oral potassium, oral calcium, and IV magnesium. He was started on basal insulin in the afternoon with a high-dose insulin sliding scale. The IV insulin was discontinued eight (8) hours after presentation. The next day, his heart rate was 65, blood pressure was 148/65, glucose was 232 mg/dl and the total carbon dioxide was 18. He was started on Lantus and insulin sliding scale, and the acidosis had improved. Psychiatry indicated to restart Abilify, Xanax, Topamax, and Trazodone. Case management assistance was obtained to procure diabetic testing supplies and medications. His insulin was sent to the inpatient pharmacy as he was unable to obtain his insulin in the outpatient setting due to his homelessness. At the time of admission, his inpatient care was expected to exceed two midnights. He trended toward wellness quicker than expected and was medically stable for discharge.

"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. 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 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 full hospital admission is substantiated.