Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Insulin-dependent diabetes mellitus (IDDM).
Treatment:  Inpatient Hospital Admission.

The insurer denied inpatient hospital admission.  The denial is overturned.

The patient is an adult male with the medical diagnosis of Type I, or insulin-dependent diabetes mellitus (IDDM) who came to the hospital with complaints of weakness and nausea and vomiting x1 day. The patient reported that he ran out of his Lantus. ED (Emergency Department) vital signs were normal except for blood glucose > (greater than) 600 mg/dl (milligrams per deciliter). Labs were notable for Beta Hydroxy Butyrate > (greater than) 4.5, HCO3 (bicarbonate) 16, GL (glucose level) 670, AG (albumin/globulin) 29, pH of 7.28, venous lactate 3.9, creatinine 1.14 (baseline 0.67) and was Covid Positive. In the ED (Emergency Department), he received 2 L (liters) of IV (intravenous) normal saline, regular insulin drip, Paxlovid and was admitted to medical step down for further management and glycemic control. As an inpatient, anion gap was closed at 0250. He was kept on IV (intravenous) LR (Lactated Ringers) with basal insulin regimen. AKI (acute kidney injury) improved to baseline on day #3. He was kept on basal insulin regimen. 

Potassium required repletion on day #2 and magnesium required repletion on day #3. He was discharged on day #4.

This patient had high anion gap metabolic acidosis with venous pH < (less than) 7.30 due to DKA (diabetic ketoacidosis) with the need of insulin drip. He had acute kidney injury requiring IV (intravenous) hydration > (greater than) 48 hours to allow for 
resolution. According to the provider, given evidence of end organ damage, and also Covid infection in an immunocompromised state, it was appropriate to monitor him for respiratory decompensation.

The Inpatient Hospital Admission was medically necessary.

The patient had biochemical evidence of DKA (diabetic ketoacidosis) based on BG (blood glucose) greater than 250 with elevated ketones (beta-hydroxybutyrate level greater than 4.5), elevated anion gap and low pH level (pH less than 7.30).

"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 (diabetic ketoacidosis) and HHS [hyperglycemic hyperosmolar state]. 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 (diabetic ketoacidosis) or HHS [hyperglycemic hyperosmolar state] presentation in comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA (diabetic ketoacidosis), 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 (diabetic ketoacidosis) or HHS [hyperglycemic hyperosmolar state] during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis" (Gosmanov, et al., 2018).