Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional - Diabetic ketoacidosis.
Treatment: Inpatient Hospital.
The insurer denied Inpatient admission.
The denial is upheld. 

The patient is a female with a past medical history significant for diabetes mellitus and hypertension who presented to the hospital with complaints of nausea and vomiting. Her symptoms began several days before the presentation and were associated with abdominal pain. The patient described the abdominal pain as generalized. The patient denied fever, chills, shortness of breath, cough, chest pain, or palpitations. She denied urinary symptoms or changes in bowel patterns. When seen by the admitting physician, the patient's temperature was 37.2 degrees Celsius (C), blood pressure was 138/77, respiratory rate was 29 breaths/min, and oxygen saturation was 98 percent (%) on room air.
The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that sodium was 129, potassium was 3.4, chloride was 85, blood urea nitrogen (BUN) was 32, creatinine was 1.5, and glucose was 173. The patient had ketones in her urine. Her potential hydrogen (pH) was 7.43, and bicarbonate was 36. The patient tested positive for coronavirus 2019 (COVID-19).
The patient was admitted to the hospital with a diagnosis of diabetic ketoacidosis, hypertension, and urinary tract infection. Another clinical diagnosis included hypernatremia, hyperkalemia, and alcohol abuse. The patient was admitted to the medical floor and received treatment with intravenous fluids.
The admitting physician stated that the patient did not need treatment with Remdesivir or Decadron for COVID-19 infection since the patient had no respiratory symptoms and was not hypoxic. Treatment with lisinopril was placed on hold due to acute kidney injury. The patient received amlodipine. The urine culture came back positive for Escherichia coli and the patient received treatment with oral antibiotics. During the hospital stay, the patient's clinical condition improved. She tolerated her diet and was transitioned to outpatient care.
At issue is the medical necessity of the inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of an inpatient admission was not medically necessary for this patient.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was very short.  There was no evidence that the patient had acidosis since the venous pH was 7.43. The ketosis was related to mild dehydration due to acute gastroenteritis symptoms caused by COVID-19 infection and diminished oral intake. At the time of the initial evaluation, the patient had an increased anion gap, which was related to her acute kidney injury, which was effectively treated within a short period of time. It was clearly indicated in the documentation, that within the first day of the hospitalization, the anion gap closed and the acute kidney injury that was present at the time of admission resolved. Furthermore, the patient's oral intake gradually improved. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.
Therefore, the requested health service/treatment of an inpatient admission was not medically necessary.