Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic Ketoacidosis 
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient is an adult with a history of poorly controlled diabetes mellitus (DM) who presented to the emergency room (ER) with abdominal pain. The patient was in diabetic ketoacidosis (DKA) versus hyperosmolar syndrome with a blood sugar (BS) of 541. The patient had a hemoglobin of 6.7, hemoglobin A1C (glycated hemoglobin) of 15.5, elevated osmolality of 314, venous blood gas pH (potential of hydrogen) of 7.3 and glucosuria of > (greater than) 1000. Cannabinoids were detected on the urine sample. The patient was given intravenous (IV) fluids, insulin and 2 units of packed red blood cells (PRBCs).

The patient was in DKA. The patient had a hemoglobin of 6.7. Treatment included correction of the fluid and electrolyte abnormalities, the administration of insulin, and PRBCs. For this patient therapy requires frequent clinical and laboratory monitoring and the identification and treatment of any precipitating events. This patient's therapy cannot be managed in another setting than an acute care setting.

Per Umpierrez, G. and Korytkowski M. (2016), DKA, hyperglycemic hyperosmolar state (HHS), and hypoglycemia are serious complications of DM that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopenia and severe hyperglycemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is < (less than) 1% (percent). Mortality among patients with HHS is 10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age > 60 years. Hypoglycemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycemia are likely to experience a long duration of hospital stay and increased mortality.

DKA and HHS are acute metabolic complications of DM that can occur in patients with both type 1 and 2 DM. 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. Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis (Gosmanov, et al, 2018).

Per Benoit, S. R., et al (2020), in 2014, there were a total of 184,255 and 27,532 events for DKA and HHS, respectively. The majority of DKA events occurred in young adults aged 18-44 years (61.7%) and in adults with type 1 diabetes (70.6%), while HHS events were more prominent in middle-aged adults 45-64 years (47.5%) and in adults with type 2 diabetes (88.1%). Approximately 40% of the hyperglycemic events were in lower-income populations. Overall, event rates for DKA significantly increased from 2009 to 2015 in both ED (annual percentage change [APC] 13.5%) and inpatient settings (APC 8.3%). A similar trend was seen for HHS (APC 16.5% in ED and 6.3% in inpatient). The increase was in all age groups and in both men and women.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.