Appeal type: Medical necessity
Decision: Overturned

Diagnosis: diabetic ketoacidosis (DKA)

Treatment: inpatient admission)

The insurer denied coverage for Inpatient admission

The denial is overturned


 
The patient has a history of type two diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia. The patient presented to the emergency room (ER) with nausea, vomiting, and elevated blood sugars. The patient was found to be in diabetic ketoacidosis (DKA) due to medication noncompliance. The patient was given insulin and her electrolytes improved. The patient was provided diabetic education and was discharged.

The patient presented to the emergency department (ED) with nausea and vomiting. The patient has not been taking her medications as prescribed. The patient's vital signs were heart rate 105, blood pressure 95/71, respiratory rate 16, and temperature 98.7 degrees Fahrenheit. The labs showed acute kidney injury (with creatinine of 2.59 up from 0.8), hyponatremia (with sodium of 129), and elevated white blood count. The patient was admitted for hyperglycemia, acidosis, and treatment of acute kidney injury (AKI). While inpatient, she was given intravenous fluids of normal saline, blood sugars checked four times a day, and administered insulin, and monitoring of labs. The patient was given diabetic education and glucometer with strips. The patient's hyperglycemia and AKI resolved. The patient was then discharged to home. 

Per Davies, M. J., et al. (2018), "Alternatively, the addition of insulin to oral medication regimens is well established. In particular, using basal insulin in combination with oral medications is effective, and has less hypoglycemia and weight gain than combinations using premixed insulin formulations or prandial insulin. A standard approach for optimizing basal insulin regimens is to titrate the dose based on a target fasting glucose concentration, which is a simple index of effectiveness. Either NPH insulin or long-acting insulin analogs are efficacious for controlling fasting glucose, although basal analog formulations show reduced risks of hypoglycemia, particularly overnight, when titrated to the same fasting glucose target as NPH insulin."

According to Zhong, V. W., Juhaeri, J. &amp; Mayer-Davis, E. J. (2018), "For type 1 diabetes mellitus (T1DM), the incidence of hospital admission for DKA increased between 1998 and 2007 and remained static until 2013. The incidence in 2013 was higher than that in 1998. For type 2 diabetes mellitus (T2DM), the incidence increased 4.24%  annually between 1998 and 2013. The length of hospital stay decreased over time for both diabetes types. Adults with T1DM were more likely to be discharged within 2 days compared with adults with T2DM. The 30-day readmission rate was higher in T1DM than in T2DM but remained unchanged for both diabetes types over time. Trends in 30-day and 1-year all-cause mortality rates were also stable, with no difference by diabetes type."

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

The medical necessity for the inpatient admission is substantiated.