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 a male with a history of diabetes, asthma, gout, and hypertension who presented to the Emergency Department (ED) from a clinic for complaints of hyperglycemia.  The patient's finger stick glucose was too high to read on the machine.  The patient reported lack of compliance with his home insulin regimen.  The patient also reported a two week history of urinary frequency, fatigue, and blurred vision.  In the ED, the patient's glucose level was 575. The patient's heart rate and blood pressure were elevated with blood pressure (BP) of 158/108, pulse of 111, temperature of 97.9, and respiration of 16.  The patient's chest X-ray showed no acute disease.  The patient's anion gap was 16, beta-hydroxybutarate was 2.89, white blood cell (WBC) count was 13.7, and ketones were positive in the blood.  There was no acidosis.  

The patient was treated with 9 units of intravenous (IV) insulin, a 3 liter IV normal saline (NS) bolus, 20 units of IV potassium, and oral potassium. The patient's glucose level and anion gap remained elevated.  The patient's repeat finger stick was 555 for which an additional 10 units of IV insulin was given.  The patient was admitted with diabetic ketoacidosis (DKA).  The patient was started on 27 units of Lantus.  The patient's electrolytes were monitored and potassium was replaced.  Endocrinology consulted over the case, and they recommended administering 15 milligrams of Actos a day and 30 units of Lantus at night, and continue Metformin 1000 milligrams every 12 hours.  

The Inpatient Admission was not considered medically necessary for this patient.  The patient did not meet full criteria for DKA based on the evidence that this patient's potential of hydrogen (pH) was normal and he was not acidotic.  Although, the patient had hyperglycemia with ketosis, the ketosis was mild.  The patient didn't have severe electrolyte abnormalities and his anion gap elevation was not severe.  The patient's beta hydroxybutyric acid levels were also not high enough to meet diagnostic criteria.  The patient was alert and was not in respiratory distress.  

As per literature review, DKA is characterized by the triad of hyperglycemia, anion gap metabolic acidosis, and ketonemia. Metabolic acidosis is often the major finding.  The serum glucose concentration is usually less than 800 and commonly 350 to 500.  Where available, serum beta hydroxybutyric acid levels>or = 3.0 and>or = 3.8 in children and adults, respectively, in the presence of uncontrolled diabetes can be used to diagnose DKA and may be superior to the serum bicarbonate level for that purpose.  The marked variability in the relationship between beta hydroxybutyric acid and bicarbonate level is probably due to the presence of other acid-base disturbances, especially hyperchloremic, non-anion gap acidosis (Sheikh-Ali M, Karon BS, Basu A, Kudva YC, Muller LA, Xu J, Schwenk WF, Miles JM., 2008).  

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

The carrier's denial of coverage for the Inpatient Admission should be upheld.  The medical necessity is not substantiated.