Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 Diabetes Mellitus (T1DM). 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adolescent male followed by his pediatric endocrinologist for Type 1 Diabetes Mellitus (T1DM). He presented to the emergency department (ED) with nausea, severe hyperglycemia in the 300-400 range for the past several weeks. He was found to be tachycardic, hyperglycemic at 477 mg/dl (milligrams per deciliter), acidotic with anion gap of 24, pH (potential of hydrogen) 7.28. He evidenced acute kidney injury with creatinine 1.2, and ketonuria. He was also found to be positive for Parainfluenza Type 4. He was started on insulin drip and fluids, admitted for acute dehydration, ketoacidosis, and pre-renal acute kidney injury, and for close monitoring. 

The Inpatient Hospital Admission was medically necessary. 

Although the patient may be classified as having had mild DKA (diabetic ketoacidosis) based on his pH and bicarbonate level, there were some extenuating circumstances that justified inpatient care. 

The patient's acidosis persisted despite initiation of intravenous (IV) insulin therapy. This is especially concerning in the setting of an underlying infection, as was the case in this patient. Further, there was evidence of dehydration as well as acute kidney injury.
All patients with DKA (diabetic ketoacidosis) should be managed in a unit with personnel and facilities capable of frequent monitoring of clinical symptoms, fluid status, and laboratory results. (Glaser, et al. 2022). The experienced clinician is in the best position to determine the safest place for therapy within a particular institution. In most tertiary care institutions, patients should be triaged as follows: 
A pediatric intensive care unit (PICU) or specialized inpatient diabetes care unit is appropriate for patients with severe DKA (diabetic ketoacidosis) or signs of or risk factors for cerebral injury, which include the following: Altered consciousness, Age younger than five years, Severe acidosis (venous pH <7.1), Low pCO2 (partial pressure of carbon dioxide) (20 mmHg [millimeters of mercury]), High BUN (blood urea nitrogen), Significant hyper- or hypokalemia, or other severe electrolyte disturbances.
This patient did have low pC02 (partial pressure of carbon dioxide). Further, in most institutions, all patients receiving IV (intravenous) insulin or needing frequent monitoring are hospitalized in the pediatric intensive care unit (PICU). The regular inpatient care area is appropriate for patients with mild to moderate uncomplicated DKA (diabetic ketoacidosis), but only if this unit is capable of providing close monitoring and IV (intravenous) in most institutions, this is not possible. 

Emergency department care with outpatient follow-up may be appropriate for patients with established diabetes and very mild DKA (diabetic ketoacidosis). In some cases, initial IV (intravenous) fluid and insulin therapy in the emergency department can significantly improve the clinical picture and allow the medical team to discharge the patient to home. 

However, in this patient, it was apparent that inpatient care was indicated because his acidosis did not immediately resolve even after insulin administration, based on the timeline of resolution of his acidosis. As previously mentioned, the patient did have AKI (acute kidney injury), which is present in 43-64% of patients admitted for DKA (diabetic ketoacidosis). This needs to be carefully managed as well with restoration of fluid, electrolyte and glycemic balance. (Hursh, et al. 2017.) 

Hence, inpatient care was medically necessary in this situation.