Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Diabetic ketoacidosis

Treatment: Inpatient hospital admission

The insurer denied coverage for Inpatient hospital admission. The denial was modified.

This patient is a male who was brought into the emergency department after a fall.  The patient's vital signs upon arrival were normal.  The patient stated he had an epidural on Friday and since then he had not been walking well.  The patient reported a sensation of being off balance.  He was in no apparent distress.  There was normal range of motion to all extremities with no tenderness noted.  He was alert and oriented x3 with a normal steady gait.  He was 5/5 strength all extremities and there were no focal sensory deficits.  It was recommended the patient undergo laboratory studies as well as diagnostic studies.   

The patient was also given a lactated Ringers as well as insulin to treat elevated blood sugar, lorazepam, and lidocaine patch.  The patient's laboratory studies revealed glucose of 416 with a lactic acid of 2.0 and creatinine of 1.4.  The patient had an elevated anion gap at 20.  The patient imaging that included MRI of the lumbar spine showing no acute fracture, or neural foraminal stenosis.  There was a vertebral hemangioma at T10.  The documentation did indicate the patient was recommended to be admitted for diabetic ketoacidosis.  The patient was to continue with treatment however he continued to have a rising anion gap.  He was treated with fluids as well as medication to include an insulin drip.  He was seen by endocrinology.  The patient did improve slowly, and the insulin drip was discontinued two days prior to discharge.  The patient did not have any further significant abnormalities.  The patient continued to improve and given the period of stability, he was discharged.

According to current literature an inpatient admission is appropriate for diabetic ketoacidosis when there is evidence the patient has hyperglycemia as well as ketonuria or ketonemia, acidosis as evidenced by an arterial or venous pH of less than 7.3 and there is a need for inpatient management.  The submitted documentation detail the patient presented after a fall with serum glucose of 416.  The documentation also detailed the patient's anion gap was elevated as well as the patient's hydroxybutyrate.  The patient also had an elevated lactic acid.  Therefore, this patient was in need of a hospital admission.  The patient failed observation care given the inability of stabilization of laboratory studies despite treatment.  Furthermore, the glucose management regimen was not suitable for outpatient setting given the needed an insulin drip.  The patient's insulin drip was discontinued when the patient was noted to be more stable.  Therefore, it does appear a portion of the inpatient hospital admission was appropriate in order to appropriately manage and stabilize this patient.  The patient presented as a medically fragile patient and was in need of a 2-day stay.  As such, inpatient hospital admission was medically necessary. Inpatient stay was not medically necessary.

The health plan did not act reasonably with sound medical judgment in denying admission.

Based on the above, the medical necessity for the inpatient hospital admission for 2 days is substantiated. Medical necessity for inpatient hospital admission for the days thereafter is not substantiated.  The insurer's denial is modified.