Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission 
 The denial is upheld

This is a patient with a history of diabetes mellitus and chronic kidney disease. The request is for coverage of inpatient stay.

The patient presented to the emergency department (ED) for hyperglycemia. He also had headache, body aches, and fatigue. BP (blood pressure) was 151/71, HR (heart rate) 88, RR (respiratory rate) 18, 97.7F (Fahrenheit), 100% (percent) oxygen saturation.  On exam, he was alert and oriented. Labs showed glucose of 767, creatinine 2.04, K (potassium) 6.3, BHOB (beta-hydroxybutyrate) 0.3, osmolality 298. An ECG (electrocardiogram) did not show abnormalities. She received 10 units of insulin and 2g (grams) of calcium gluconate and IV (intravenous) fluids. Repeat labs show potassium of 4.4, and creatinine of 1.56. His CXR (chest x-ray) showed possible pneumonia and he started on empiric antibiotics. The patient was placed on insulin Lantus and lispro. 

"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 special situations such as DKA or HHS presentation in the comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during 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, AR. et al. 2018).

"Abstract Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinogenic and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies." (Fayfman, M. et al. 2017).
                                             
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.