Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus

Treatment is an inpatient admission 	

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient is a male with history of type 2 diabetes, coronary artery disease (CAD), and hypertension (HTN).  The patient presented to the emergency room (ER) with complaints of lower extremity pain, polyuria, and polydipsia. Blood glucose level was 802. The patient was admitted with diabetes. He was started on Gabapentin for neuropathy. Tramadol was given for pain. The patient was given intravenous (IV) fluids, sliding scale insulin, Lispro, and Detemir. He left against medical advice (AMA).

Gosmanov AR et al. (2021), "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 the comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis"

Fayfman M, Pasquel FJ, Umpierrez GE. (2017), "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 1,2. The rate of hospital admissions for HHS is lower than for DKA, accounting for less than 1% of all diabetes-related admissions 3,4. Both disorders are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management is paramount to improve patient outcomes. The mainstays of treatment in both DKA and HHS are aggressive rehydration, insulin therapy, electrolyte replacement, and discovery and treatment of underlying precipitating events. Herein we review the epidemiology, pathogenesis, diagnosis, and provide practical recommendations for the management of patients with hyperglycemic emergencies."

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.