Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 diabetes.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission. 
The denial is overturned.

According to the medical records, the patient is male with a diagnosis of Type 1 diabetes mellitus. He presented to the hospital with complaints of a low blood glucose level. His blood glucose level was 42 at home. He was given 1 milligram (mg) of Glucagon en route to the emergency room (ER). On examination he had a delayed capillary refill of 2 to 3 seconds. His blood pressure was 169/99, pulse was 106, temperature 36.9 C (Celsius) (98.4  F (Fahrenheit) orally, respiratory rate 18, and SpO2 (oxygen saturation) 99% on room air. His white blood cell (WBC) count was elevated. His blood glucose level was 279. He was admitted with hypoglycemia. The patient had a low hemoglobin of 9.8 g (grams)/dL (deciliter), a low hematocrit of 27.3%, with a left shift given elevated Neutrophils of 92.8%. The patient also had an elevated lactic acid of 1.78 mmol (millimoles)/L (liter), an elevated creatinine of 2.16, and an elevated blood urea nitrogen of 23.4. He was also found to be acidotic with an arterial pH (potential of hydrogen) of 7.33, PCO2 (partial pressure of carbon dioxide) of 25.6, and HCO3 (bicarbonate) of 13.2. An electrocardiogram (ECG) demonstrated sinus tachycardia. Chest radiograph demonstrated no acute disease. 

"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 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 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).

"When hyperglycemia is left untreated, it can lead to many serious life-threatening complications that include damage to the eye, kidneys, nerves, heart, and peripheral vascular system. Thus, it is vital to manage hyperglycemia effectively and efficiently to prevent complications of the disease and improve patient outcomes." (Mouri, M., & Badireddy, M. 2021).                                                         
      
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.