Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic Ketoacidosis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a past medical history significant for type II diabetes mellitus associated with gastroparesis who presented to the emergency department with complaints of nausea, vomiting, diarrhea, and abdominal pain.
Reportedly, the patient was recently admitted to the hospital for treatment of diabetic ketoacidosis, and was briefly in the intensive care unit (ICU) on an insulin drip, but at that time she decided to leave the hospital against medical advice.
The review of systems was also positive for chills, night sweats, and a sensation that her food was not going through the gastrointestinal tract. The patient stated that despite taking her usual insulin regimen, her blood sugar still remained persistently elevated.
Upon initial evaluation in the emergency department, the patient was afebrile. The heart rate was 99 beats per minute (bpm), respiratory rate 20 breaths/minute, blood pressure 180/134, and oxygen saturation was normal on room air.
The patient was awake and alert and oriented times three. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck exam was unremarkable. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. There was tenderness to palpation in the epigastrium, but otherwise, the abdomen was soft and not distended. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the serum sodium was 139, potassium 3.9, chloride 106, bicarbonate 21, blood urea nitrogen (BUN) 6.2, creatinine 0.5, and glucose 48.
The patient was admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). She received treatment with intravenous fluids and was given insulin. Reglan was initiated for nausea and to improve gastric motility. According to the medical records, the patient's anion gap initially closed but subsequently reopened, and the hydroxybutyrate became elevated again. At that time, insulin was utilized and the patient's symptoms improved with normalization of the labs and closure of the anion gap again.
During the hospital stay, the patient was seen by an endocrinologist, and the insulin regimen was modified. In the hospital, the patient was also evaluated for abdominal pain, which was attributed to severe gastroparesis. The patient continued to complain of dysphasia and a feeling that her gastrointestinal tract was obstructed.
The patient was seen by a gastroenterologist and the dose of Reglan was increased. The patient continued to receive treatment with Zofran and erythromycin for gastroparesis. Despite this aggressive regimen, the patient still complained of abdominal pain that only responded to treatment with Percocet.
The patient's clinical condition gradually improved and she was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The admission was medically necessary at the acute inpatient level of care.
This patient presented to the hospital with complaints of abdominal pain, nausea, vomiting, and diarrhea. At the time of admission, the patient was diagnosed with diabetic ketoacidosis. She received treatment with insulin and intravenous fluids.
In the hospital, the patient was seen by an endocrinologist who suggested that the patient likely had starvation ketosis and not diabetic ketoacidosis. Having said that, the patient's starvation ketosis was caused by dehydration and severely diminished oral intake because of the persistent abdominal pain due to gastroparesis.
Therefore, she required continuous administration of intravenous fluids to treat dehydration in the setting of severely diminished oral intake. This patient also needed a complex treatment of gastroparesis, which was provided in order to ensure improvement in her abdominal pain with subsequent improvement of oral intake.
Based on the review of the medical records, the complexity of the patient's condition and the services provided went far beyond what can be accomplished at a lower level of care. Therefore, the admission at the acute inpatient level of care was justified.
The patient's oral intake remained significantly diminished beyond the observation period of care, putting her at the risk of recurrent starvation ketosis, dehydration, diabetic ketoacidosis.