Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis. 

Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a female patient with a history of hypertension and newly diagnosed diabetes. The patient presented to the Emergency Room (ER) with complaints of nausea, vomiting, polyuria, and new onset palpitations. In the ER, the patient was afebrile and hemodynamically stable. The patient was noted to have acidemia, an elevated anion gap, and elevated b-hydroxybutarate. The patient's laboratory results showed random glucose of 397, anion gap of 21, and serum carbon dioxide (CO2) of 15. An insulin drip was started. The patient's vital signs were stable. The patient was admitted for diabetic ketoacidosis (DKA). Intravenous (IV) fluids were initiated and the insulin drip was continued. The patient's anion gap closed. The patient was started on daily subcutaneous Lantus, Lispro three times daily, and a moderate correction scale. The patient was also started on rosuvastatin for an atherosclerotic cardiovascular disease score of 2.8%. The patient was clinically optimized and discharged home with instructions to follow-up with her primary care provider within one week of discharge. 

As per Lizzo et al. (2020), DKA "is characterized by hyperglycemia, acidosis, and ketonemia. It is a life-threatening complication of diabetes and typically seen in patients with type-1 diabetes mellitus, though it may also occur in patients with type-2 diabetes mellitus. In most cases, the trigger is new-onset diabetes, an infection, or a lack of compliance with treatment." As per the American Diabetes Association (2020), "Diabetic ketoacidosis (DKA) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death...Treatment for DKA usually takes place in the hospital." 

As per Gosmanov et al. (2014), "The therapeutic goals of [diabetic ketoacidosis (DKA)] management include optimization of 1) volume status; 2) hyperglycemia and ketoacidosis; 3) electrolyte abnormalities; and 4) potential precipitating factors. The majority of patients with DKA present to the emergency room. Therefore, emergency physicians should initiate the management of hyperglycemic crisis while a physical examination is performed, basic metabolic parameters are obtained, and final diagnosis is made." 

In this case, the patient had new onset diabetes and presented with documented evidence of a hyperglycemic emergency, specifically DKA that meets the criteria for inpatient admission. The patient was noted to have acidemia, an elevated anion gap, and elevated b-hydroxybutarate. The patient's laboratory results were as follows: random glucose of 397, anion gap of 21, and serum carbon dioxide (CO2) of 15. Therefore, the inpatient hospital admission is considered medically necessary. 
                                                       
Based on the medical facts from the available records, claim documentation, and any additional information obtained from the patient's treating provider(s) from the perspective of Endocrinology, Diabetes, & Metabolism/Internal Medicine, the inpatient hospital admission was medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.