Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type I Diabetes Mellitus

Treatment inpatient emergency admission

The insurer denied coverage for inpatient emergency admission.

The denial is overturned.

The patient presented to the Emergency Department (ED) for evaluation of epigastric pain with nausea, vomiting, frequent thirst, urinary frequency and 25 pound weight loss. Vital signs: blood pressure (BP) 121/79, pulse 103 beats per minute (bpm), temperature 97.5 Fahrenheit, respirations 17/min. He had been seen the day prior by his primary medical doctor, and was informed his glucose level was 909, with A1c (glycated hemoglobin) of 14 percent. Labs: sodium 128 (L [low]), chlorine 90(L), Creatinine 1.41 (H [high]). and glucose 755 (H). The beta-hydroxybutrate was 1.2 (H). The urinalysis glucose was (>1000). The patient was admitted for management of new onset diabetes, infectious workup and to rule out diabetic ketoacidosis (DKA) versus hyperosmolar hyperglycemic syndrome (HHS). The patient was started on insulin and educated about diabetes management. He was discharged with instructions for outpatient follow up.

The patient had very severe hyperglycemia, with a plasma glucose of over 900 upon initial presentation, along with normal bicarbonate levels, or lack of acidosis, which may be compatible with Hyperosmolar Non-ketotic state, which is a medical emergency that carries a high risk of morbidity and mortality.      

The inpatient emergency admission is considered medically necessary for this patient.  

The patient presented to the emergency department (ED) for evaluation of acute gastrointestinal (GI) issues, namely abdominal pain, nausea, vomiting, frequent thirst, urinary frequency, and a 25 pound weight loss, after being seen at his primary care provider's office, with a plasma glucose of over 900, and a baseline A1c of 14 percent.

Arterial blood gas (ABG) was not obtained, but venous blood glucose (BG) was obtained. Bicarbonate was greater than 18, ruling out acidosis, and anion gap was not elevated at ten. He was not stuporous on admission, but symptomatic from the GI standpoint. The urinalysis glucose was (greater than 1000). The patient was admitted for management of new onset diabetes, infectious workup, and to rule out diabetic ketoacidosis (DKA) versus hyperosmolar hyperglycemic syndrome (HHS). 

According to the ADA (American Diabetes Association) guidelines:  "Both diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are medical emergencies that require prompt recognition and management.  Diabetic ketoacidosis (DKA) usually evolves rapidly, over a 24-hour period. In contrast, symptoms of hyperosmolar hyperglycemic state (HHS) develop more insidiously with polyuria, polydipsia, and weight loss, often persisting for several days before hospital admission.  The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and weight loss. As the degree or duration of hyperglycemia progresses, neurologic symptoms, including lethargy, focal signs, and obtundation, can develop. This can progress to coma in later stages. Neurologic symptoms are most common in HHS, while hyperventilation and abdominal pain are primarily limited to patients with DKA.  
Successful treatment of Diabetic ketoacidosis (DKA) and HHS requires correction of dehydration, hyperglycemia, and electrolyte imbalances; identification of comorbid precipitating events; and above all, frequent patient monitoring.

Therefore, the inpatient emergency admission is considered medically necessary for this patient. 

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

The insurers denial of inpatient emergency admission is overturned. Medical necessity is substantiated.