Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

According to the medical records, the is a patient with a history of diabetes and chronic kidney disease (CKD) III. 

He presented to the emergency room (ER) with complaints of hyperglycemia. He was recently hospitalized and started on Basaglar and Admelog. On arrival to the ER, his blood pressure was 137/65, pulse 85 beats per minute, glucose greater than (>) 500 milligrams (mg) per deciliter (dl) (mg/dl) times three. Laboratory results included: sodium 131, potassium 5.7, glucose 597 mg/dl, lactic acid 2.5, basic metabolic panel (BMP): glucose 640 mg/dl, blood urea nitrogen (BUN) 64, creatinine (CR) 2.76, chloride (CL) 96, potassium 5.8, and sodium 128. His glycated hemoglobin (HbA1c) was greater than 14 percent (%). The patient was not taking long-acting insulin at home. Oral hypoglycemic were held. The dosage of long-acting insulin was decreased. The patient had an acute kidney injury. 

The patient is a noncompliant patient with type 2 diabetes who only had severely hyperglycemia and non-severe creatinine elevation above baseline, with no mental status changes or signs of hemodynamic instability. The patient had already been admitted and discharged for the same issue. He did not even require an insulin drip on admission. He also failed to meet diagnostic criteria for diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HONK), based on American Diabetes Association and hospital admission guidelines. Therefore, based on a review of the documentation, this inpatient admission was not medically necessary. 

The criteria for DKA are the following:

Blood glucose (BG) greater than 250 milligrams per deciliter (mg/dl), (greater than 13.9 millimoles per litre (mmol/L)) with:
1), arterial pH (potential for hydrogen) less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L) and
2) ketonuria and/or ketonemia.

"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." (Fayfman, M. et al. 2017).
"When hyperglycemia is left untreated, it can lead to many serious life-threatening complications that include damage to the eye, kidneys, nerves, heart, and peripheral vascular system. Thus, it is vital to manage hyperglycemia effectively and efficiently to prevent complications of the disease and improve patient outcomes.

When evaluating a patient for hyperglycemia, the focus should be on the patient's cardiorespiratory status, mental status, and volume status. Bedside serum glucose can be obtained quickly. Testing includes serum electrolytes with the calculation of the anion gap, blood urea nitrogen and creatinine, and complete blood count. Urinalysis by dipstick assesses glucose and ketones in the urine. Arterial blood gas or venous blood gas may be necessary if serum bicarbonate is substantially reduced" (Mouri, M., & Badireddy, M. 2021).

The inpatient admission is not considered medically necessary for this patient.

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