Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Ketoacidosis
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male with uncontrolled type II diabetes mellitus, diabetic nephropathy, retinopathy, and multiple previous hospitalizations for diabetic ketoacidosis (DKA). He presented to the hospital with a one-day history of weakness, vomiting, and elevated blood sugars that exceeded 600 at home. His review of systems was positive for polydipsia and fatigue. He also reported diarrhea and loss of appetite.

Upon the initial evaluation in the emergency department, the patient was found to be hyperglycemic with blood sugars greater than 500. His anion gap was calculated at 17, which in conjunction with elevated ketones was suggestive of a diagnosis of diabetic ketoacidosis. In the emergency department, the patient was started on intravenous fluids and was given long-acting Insulin. The patient was found to be Coronavirus (COVID-19) positive, however, he had no pulmonary symptoms or abnormalities on the chest x-ray.

When the patient was seen by the admitting physician his blood pressure was 173/81, pulse rate 95 beats per minute (bpm), respiratory rate 18 breaths per minute, and his oxygen saturation was 98 percent (%). The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) examination was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. His lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient's abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound.

The laboratory evaluation revealed that his sodium was 129, potassium 5.8, chloride 98, bicarbonate 15, blood urea nitrogen (BUN) 51, creatinine 4.01, and his glucose was 592. His white blood cell count was 17.3, hemoglobin 13.2, hematocrit 30.7, and his platelets were 358. The liver function tests were unremarkable. 

The patient was admitted to the hospital with a diagnosis of diabetic ketoacidosis that was attributed to medical noncompliance, as well as the COVID-19 infection. By the time the patient was seen by the admitting physician, his anion gap closed. The patient was started on an Insulin regimen. Laboratory studies were obtained for the evaluation of diarrhea and the patient was started on intravenous fluids.

It was also mentioned that the patient had acute kidney injury superimposed on chronic kidney disease. The baseline serum creatinine was in the range between 2.5 and 3. The treatment with Losartan that the patient took at home was discontinued due to hyperkalemia. During the hospital stay, the patient remained afebrile and hemodynamically stable. His clinical condition improved. 

The requested health service/treatment of inpatient admission was not medically necessary for this patient. The patient had a history of chronic kidney disease and his creatinine was a little worse than the baseline, however, this did not meet the Kidney Disease Improving Global Outcomes (KDIGO) criteria for acute kidney injury. At the time of the initial evaluation, the patient had hyperkalemia, however, just a few hours later the patient's serum potassium levels normalized. The COVID-19 infection that was diagnosed at the time of admission was asymptomatic.

After a short period of treatment with intravenous fluids, the patient's kidney function normalized. Overall, the patient remained in stable clinical condition, tolerated his diet, and was discharged from the hospital.

The patient's condition had significantly improved even before the patient was seen by the admitting physician. It was clearly indicated that by the time the patient was seen by the admitting physician, the anion gap closed. Therefore, the patient did not require treatment with an Insulin infusion.