Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia. 
Treatment: Inpatient admission. 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is an adult with a history of diabetes mellitus, chronic kidney disease, lupus, bipolar disorder, gout, chronic pancreatitis, hypertension, and cerebrovascular accident (CVA), who presented for an emergency evaluation due to weakness and reported chest pain. It was noted the patient indicated he was not sure when he last used insulin. On examination, the patient was afebrile with temperature 97.6 degrees Fahrenheit (F), bradycardic at pulse 59 beats per minute, and hypertensive with blood pressure 141/88 millimeters of mercury (mmHg). It was noted the patient appeared drowsy in four-point restraints, pale, with poor skin turgor, and tophi on the finger. Physician noted cardiac and lung exam as normal. Neuro noted as alert and oriented, moving all extremities. 

Initial laboratory studies were remarkable for anemia with hemoglobin 10.4, hyperglycemia with glucose 538, lactic acidosis with lactate 2.6, followed by 3.6, CO2 (carbon dioxide) of 26 sodium 132, potassium  5.0, pH (power of hydrogen) venous blood gas (VBG) of 7.35., elevated creatine kinase (CK) at 497, and troponin elevation at 74.9, followed by 70. B-type natriuretic peptide (BNP) was 46. Osmolality was 294 and betahydroxy was .05. Urine ketones were negative. An electrocardiogram (EKG) demonstrated left anterior fascicular block, sinus bradycardia and old inferior myocardial infarction (MI). A chest radiograph demonstrated no acute pulmonary disease, but questionable oblonged 3.1 centimeters (cm) radiopacity in the right lung base. In the emergency department (ED), the patient was administered Benadryl, Haldol, insulin, lorazepam, midazolam, pantoprazole, and three liters (L) of normal saline intravenous (IV) fluids. 

Hyperglycemia was most likely due to medication noncompliance. The data do not support either diabetic keto acidosis (DKA) or hyperosmolar syndrome. 

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

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital is not substantiated.