Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  New onset uncontrolled diabetes mellitus with hyperglycemia and diabetic ketoacidosis (DKA).
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned. 

This is a female patient with a medical history of obesity.  The patient presented to the Emergency Department (ED) for the complaint of 1 week history of increased urinary frequency, every 2 hours during the day and every hour nocturnally.  In addition, the patient also reported polydipsia, dysuria, and new thick white vaginal discharge.  The patient initially presented to Urgent Care and was found to be hyperglycemic with glucose greater than 500, and was referred to the ED for further treatment.  The patient's body mass index (BMI) was 47.2 upon physical examination.  The patient's lab work revealed point of care (POC) blood glucose greater than 530, sodium 129, anion gap 20, serum glucose 633, and hemoglobin A1c (HgA1c) 13.5%.  The patient was admitted to the Medicine unit with the diagnosis of new onset uncontrolled diabetes mellitus with hyperglycemia and diabetic ketoacidosis (DKA).  Once all risks were addressed and the patient achieved hemodynamic stability, the patient was cleared for discharge and was scheduled to follow-up with her primary care physician and endocrinologist in 1 week.

As per Eledrisi et al., "Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states...." 

As per Fayfman et al., "Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in patients with diabetes....  Early diagnosis and management is paramount to improve patient outcomes.  The mainstays of treatment in both DKA and HHS are aggressive rehydration, insulin therapy, electrolyte replacement, and discovery and treatment of underlying precipitating events."

In this case, the patient met criteria for DKA, and she also had electrolyte abnormalities, such as hypokalemia that can lead to cardiac abnormalities or arrhythmias that could be potentially life-threatening.  The appropriate treatment and correction of these abnormalities require close observation and necessitate inpatient admission.  Because the patient had abnormal urinary discharge, a precipitating infection also needed to be ruled out.  If left untreated, this infection could lead to potential complications and could impair resolution of this patient's severe hyperglycemia.

Based on the medical facts from the available records, claim documentation, and any other additional information obtained from the patient's treating provider(s), and from the perspective of Endocrinology Diabetes & Metabolism/ Internal Medicine, the inpatient admission was medically necessary for this patient, who presented with severely elevated blood glucose, with an anion gap, hypokalemia, lactic acidosis, and urinary ketones in the setting of potential infection.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be overturned.