Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial was overturned in whole.

The patient is a male with a history of hypertension, diabetes, who presented to the hospital with dizziness, nausea, and elevated glucose levels. He reported excess thirst, polyuria, and polydipsia. The blood glucose value was 500. Other associated symptoms included nausea and vomiting x 2. There were no associated fevers or chills, chest pain, or abdominal pain.
Vital signs in the emergency department (ED) included a heart rate of 91, blood pressure of 126/50, and respirations of 16. White blood cell count was elevated to 12.2. Potassium was elevated at 5.5. The anion gap initially was calculated at 23. Venous blood gas was obtained, showing a pH of 7.22 and elevated beta-hydroxybutyrate.
The patient received 2 liters (L) of lactated Ringer's solution, as well as 1 L of normal saline in the ED, along with eight units of insulin bolus. He was admitted to the medical intensive care unit for the treatment of diabetic ketoacidosis (DKA). On exam, the patient appeared nontoxic, with clear lungs and regular rate and rhythm. The abdomen was benign, and no other major abnormalities on the exam.
Over the next 12 hours, serial chemistry panels were obtained, showing an improvement in the anion gap down to 17, but persistently elevated glucose levels in the 400s. Urinalysis showed significant glycosuria, but leukocyte esterase and nitrates are negative. The chest x-ray showed no evidence of infiltrates.
The patient was continued on insulin infusion per DKA protocol, with plans to transition to subcutaneous insulin when the blood glucose falls below 200. Intravenous (IV) fluids were continued.
The following day, the patient's anion gap remained normal, and blood glucose values decreased; therefore, the patient was transitioned to Lantus 15 units in the morning, and ten units at night, along with four units of lispro three times a day. Nausea and vomiting were resolved.
Endocrinology assisted in adjusting the home regimen of insulin. They changed the Lantus dosing to 28 units nightly with six units of lispro with meals. On the day of discharge, the anion gap is 12, electrolytes, and renal function are normal. The white blood cell count is 7.12.
The patient was deemed stable for discharge and set up for a follow-up appointment with primary care physician (PCP) in 1 week.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The requested health service/treatment of inpatient stay is medically necessary for this patient with diabetic ketoacidosis.
Qualifying criteria for admission to inpatient stay include the presence of blood glucose of 500, pH of the blood of 7.22, elevated anion gap, and presence of beta-hydroxybutyrate, all consistent with relatively severe diabetic ketoacidosis. The fact that the patient recovered within 24 hours is irrelevant to the discussion, as the presenting clinical picture is quite severe. It is the standard of care to admit this type of patient presentation, to the intensive care unit setting, with every hour Accu-Cheks, adjustment of an insulin drip, and a significant amount of fluids provided through an IV continuous infusion. This conclusion is supported in the national medical literature and is the standard of care. Therefore, the inpatient stay is medically indicated for this patient's presentation.