Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
The patient has a past medical history of diabetes mellitus, schizoaffective disorder, and asthma. The patient has had prior hospitalization for the same. He presented to the emergency department for urgent evaluation of pain and swelling in his finger that had been progressively getting worse over the course of a week. 

The emergency department (ED) physician ordered labs, as well as radiologic imaging, which showed an elevated blood glucose of 593 and metabolic acidosis. His vital signs were blood pressure (BP): 121/81, temperature: 37.2 degrees Centigrade (C), pulse: 88, respirations: 18, and oxygen saturation 99%. His labs were as follows: blood glucose (BG) 593, anion gap 15, beta hydroxybutyrate was elevated at 2.25, carbon dioxide (CO2) was 12 with final result, pH (potential of hydrogen) venous: 7.38 [Ref Range: 7.38 - 7.42] partial pressure of carbon dioxide (pCO2), 42 [Ref Range: 41.0 - 51.0], partial pressure of oxygen (pO2), 80, bicarbonate (HCO3), 24.5 millimoles per liter (mmol/L) [Ref Range: 22.0 - 26.0] base excess, 1.5 mmol/L.

The patient was treated with intravenous fluids, intravenous insulin infusion, intravenous antibiotics, and his wound was debrided by hand surgery, as well as cultures were obtained. The patient was appropriately admitted as an inpatient to the medical Intensive Care Unit (ICU) for diabetic ketoacidosis (DKA).

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), (greater than 13.9 millimoles per liter (mmol/L)) 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 593. He had a low carbon dioxide (CO2) or bicarbonate of 13, an anion gap of 15, and his beta hydroxybutyrate levels were elevated. The patient also had elevated urine ketones and required an insulin drip.  

Although the initial pH from the blood gas was not less than 7.35 the guideline states the diagnosis of acidosis can be established from the blood gas or the low bicarbonate levels. There can also be some early compensation for the acidosis which explains the alteration in the pH level. 

Specifically, the patient's BG was 593, with venous pH of 7.34. He had a low carbon dioxide (CO2) or bicarbonate of 12, and an anion gap of 15. The patient also had elevated serum ketones and the patient required an insulin drip. 

As above, even if the pH from the blood gas was not less than 7.35, the guideline states the diagnosis of acidosis can be established from the blood gas or the low bicarbonate levels. There can also be some early compensation for the acidosis which explains the alteration in the pH level. Finally, the overall clinical picture of the claimant is still consistent with DKA as there is a high anion gap metabolic acidosis. The inpatient hospital admission is considered medically appropriate and necessary for this patient.
"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 (hyperosmolar hyperglycemic state) 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, et al., 2017).

The health plan did not act reasonably, with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.