Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis (DKA)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

The patient has a history of traumatic brain injury, seizures, diabetes mellitus type I, post-traumatic stress disorder (PTSD), anorexia, recent diagnosis of re-feeding syndrome, and asthma who presented to the Emergency Department (ED) for an emergency evaluation due to nausea and vomiting for 8 days.

According to patient she had a 10-pound unintentional weight loss in that week. The patient complained of new wheezing, abdominal pain, nausea and vomiting. On initial presentation, the patient was afebrile (temperature of 98.1 degrees Fahrenheit), tachycardic with heart rate (HR) 118, blood pressure (BP) 109/74, and oxygen saturation of 98%. The patient's blood glucose (BG) was 76. On physical exam the patient had wheezing in the lower lung fields, epigastric and right upper quadrant tenderness to palpation. Subsequent laboratory studies were remarkable for hypoglycemia with glucose at 59, elevated anion gap, anemia with hemoglobin (Hgb) at 10.8, hematocrit (Hct) at 32, and the arterial blood gas (ABG) was significant for acidosis at 7.34. Labs were consistent with starvation ketoacidosis. In the emergency department, the patient was administered intravenous (IV) fluids, Zofran, famotidine, and bronchodilators via nebulizers. Upon serial monitoring, the patient's exam and labs showed a rapid swing in blood glucose from 182 down to 52 without ability to control these hypoglycemic episodes which was consistent with failure to achieve symptom improvement and further supporting the necessity of acute inpatient care. The patient had an anion gap of 18.

On review of the documentation, it was found that this patient is diagnosed with type I diabetes mellitus treated with insulin injections. The patient presented to the ED, with complaints of nausea and vomiting. The patient was hemodynamically stable. The admitting diagnosis was acidosis. The patient did meet diagnostic criteria for diabetic ketoacidosis (DKA) based on the American Diabetes Association (ADA) and hospital admission guidelines. The patient's blood glucose (BG) was not greater than 250 milligrams per deciliter (mg/dl), (greater than 13.9 millimoles per liter (mmol/L)), however the patient did have an arterial potential hydrogen (pH) less than 7.35. Specifically, the patient's BG was 76. ABG showed a ph (potential of hydrogen) of 7.34. She had a low carbon dioxide (CO2) or bicarbonate of 15, and an anion gap of 18. The patient had elevated serum ketones or betahydroxybutyrate levels. As such, the inpatient admission is considered medically necessary.

"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, M. 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 inpatient admission is substantiated.