Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient with a past medical history of insulin dependent diabetes mellitus and gastroparesis presented to the Interfaith Medical Center emergency department for urgent evaluation of severe and progressive abdominal pain with associated nausea and vomiting.  The patient's blood glucose (BG) was 338, with a venous potential of hydrogen (pH) of 7.36. She had a low carbon dioxide (CO2) or bicarbonate of 13, and an anion gap of 15.  The emergency department (ED) physician ordered labs as well as radiologic imaging, which showed elevated blood glucose of 342 and metabolic acidosis with an anion gap of greater than 20. She was treated with intravenous (IV) fluids, intravenous insulin infusion, and then admitted as an inpatient to the Medical Intensive Care Unit for Diabetic Ketoacidosis. The treating physician's clinical impression was High Anion Gap Metabolic Acidosis secondary to Diabetic Ketoacidosis (DKA). The patient left the hospital against medical advice (AMA). 

Treatment consisted of continuation of intravenous insulin infusion with bridging to subcutaneous insulin therapy, intravenous fluids, supplementation of electrolytes, optimization of the patient's diabetic medication, diabetic education, and close monitoring of the patient's signs and symptoms. Unfortunately, while undergoing proper and expert medical care, the patient chose to leave against medical advice. 

The patient met diagnostic criteria for Diabetic Ketoacidosis (DKA) based on the American Diabetes Association (ADA) and hospital admission guidelines. The patient's blood glucose (BG) was greater than 250 milligrams per deciliter (mg/dl) with an arterial potential hydrogen (pH) less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L) and had ketonuria and/or ketonemia. Specifically, the patient's BG was 338, with a venous pH of 7.36. She had a low carbon dioxide (CO2) or bicarbonate of 13, and an anion gap of 15. The patient also had elevated urine ketones and the patient required an insulin drip.

"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 of 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 index hospitalization should help prevent subsequent episode of hyperglycemic crisis." (Gosmanov, A.R. et al. 2018).

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.