Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Ketoacidosis. 
Treatment: Hospital admission. 
The insurer denied the hospital admission. 
The health plan's determination is upheld. 

The patient is a male with known type 1 diabetes mellitus who was brought to the emergency department (ED) by Emergency Medical Services (EMS) with a two-day history of nausea, vomiting, headache, and fatigue in conjunction with ketonuria and elevated bedside glucose (400's). He also reported two-day history of cold symptoms. His symptoms and hyperglycemia persisted despite Insulin correction. His vital signs included temperature 96, heart rate 99, respiratory rate 19, and blood pressure 108/78. The examination was significant for a tired looking patient who was hyperventilating, decreased breath sounds on the left, and non-focal neurologic examination. The bedside glucose was initially 349. The laboratory assessment (labs) revealed sodium 130, potassium 4.5, bicarbonate 12, blood urea nitrogen (BUN) 16.0, creatinine 1.2, and his glucose was 373. The urinalysis revealed a glucose greater than (>)1000 and ketones > 160. The venous blood gas was obtained with a potential hydrogen (pH) 7.22. The chest x-ray was unremarkable. He was treated with a Normal Saline bolus and continuous Insulin. 
He was diagnosed with mild diabetic ketoacidosis (DKA) secondary to viral illness and he was admitted to the Pediatric Intensive Care Unit (PICU) for further management. The viral panel testing yielded positive enterovirus/rhinovirus. The admission orders included hourly neurological checks, continuous cardiorespiratory monitoring, hourly vital signs, venous blood gas measurements every four hours, two-bag intravenous (IV) fluid management, nothing by mouth, serial labs every four hours, hourly bedside glucose, continuous Insulin infusion with transition to subcutaneous Insulin when anion gap closes, social work consultation, endocrinology consultation and a nutrition consultation.
He did well overnight, with no acute events and blood glucose in the 200's. He was actively participating in his diabetes management. The acidosis resolved so he was transitioned to subcutaneous Insulin. The endocrinologist noted wanting the patient hospitalized another night to continue diabetes education and blood glucose monitoring. He was transferred to the floor for ongoing care and subsequently discharged home. 

Diabetic ketoacidosis (DKA) is the result of deficient Insulin resulting in intracellular starvation of insulin-dependent tissues, stimulating the release of counter-regulatory hormones causing breakdown of fats and production of ketones. Its severity is defined by the degree of acidosis: mild with pH 7.2 to 7.3, moderate with pH 7.1 to 7.2, and severe less than 7.1. Symptoms of DKA include nausea and vomiting with accelerated dehydration due to urinary water loss, abdominal pain, heavy rapid breathing (Kussmaul respirations), fruity odor to the breath, diminished neurocognitive functioning, and eventual coma. Treatment involves correction of ketoacidosis, dehydration, hyperglycemia, and insulin deficiency. There are protocols that have been designed to guide management of these patients. Patients with established diabetes mellitus or those that are not severely ill with a good home environment can be managed in the outpatient setting. The more severe the presentation, with intractable vomiting or neurological changes, the more likely admission will be required. In some cases, particularly with severe DKA, Intensive Care Unit (ICU) management is necessary.
This patient with known type 1 diabetes presented with signs and symptoms consistent with DKA. He was alert, hyperventilating, with no mental status changes. He was hemodynamically stable with no evidence of mental status changes and no evidence of impending circulatory collapse.