Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus. 
Treatment: Inpatient Admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is upheld. 

The patient is a male with a history of coronary artery disease (CAD), Ventricular Ectopy status post failed ablation, HFrEF (Heart failure with reduced ejection fraction) (EF (ejection fraction) 38 percent), and peptic ulcer disease, who presented to the emergency department (ED) for elevated blood sugar of 700 mg (milligrams) /dl (deciliter), as reported by the patient. The patient endorses increased thirst and being off his diabetes medications for two years as his blood sugar had been controlled by diet. He also complained of chest pain. Ejection Fraction was 45% on echo. 

Labs: WBC (white blood cell count) 3.1, K (potassium) 4.4, GFR (glomerular filtration rate) 61, Lactate 1.7, BUN (blood urea nitrogen) 21, Creatinine 1.31, Glucose 493, Troponin-I 0.01. Vital signs: BP (blood pressure) 116/65, HR (heart rate) 76, Temp 98.6, SPO2 (Saturation of Peripheral Oxygen) 96% on RA (room air). The ED course included vitals, physical exam, ECG (electrocardiogram), monitoring blood glucose, fluids, insulin as needed and reassessment. The patient was admitted to general medicine for further evaluation and management. The patient reported occasional melena and weight loss, and an esophagogastroduodenoscopy (EGD) was performed with no source found. 

The patient failed to meet diagnostic criteria for Diabetic Ketoacidosis (DKA) based on American Diabetes Association (ADA) and hospital admission guidelines. The patient's blood glucose (BG) was greater than (>) 700 but there was no evidence of gap acidosis and by the time of admission his BG was already trending down. The patient had no evidence of hemodynamic instability. 

"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, et al., 2018). 

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in patients with diabetes. Although DKA and HHS are often discussed as separate entities, they represent points along a spectrum of hyperglycemic emergencies due to poorly controlled diabetes. Both DKA and HHS can occur in patients with type 1 and type 2 diabetes; however, DKA is more common in young people with type 1 diabetes (T1D) and HHS is more frequently reported in adult and elderly patients with type 2 diabetes (T2D). In many patients, features of the two disorders with ketoacidosis and hyperosmolality may also co-exist. The frequency of DKA has increased by 30% during the past decade, with more than 140,000 hospital admissions per year in the United States." (Fayfman, et al., 2017). 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.