Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional - Elevated blood sugar.
Treatment: Inpatient Hospital.
The insurer denied Hospital Admission.
The denial is overturned.

This patient is a female with type 2 diabetes and hypertension who presented to the emergency department with fatigue, dry mouth, shortness of breath, and elevated blood sugars for three days. The patient was reportedly noncompliant with medications, running low on Trulicity, glipizide, Toujeo, and canagliflozin. The highest blood glucose level at home was 459. The patient had a remote history of diabetic ketoacidosis (DKA) and was worried that she might develop an episode, so she came to the emergency department. The patient also ran out of her blood pressure medications.
Vital signs in the emergency department (ED) included a normal temperature, respiration rate of 20, and blood pressure of 155/101. The initial heart rate was 131. On exam, the patient appeared well-developed, well-appearing, with good hygiene, oriented times (x) 4, and with normal mouth mucosa. On cardiac exam, she was tachycardic with a regular rhythm and tachypneic but no accessory muscle use. The rest of the exam was unremarkable.
The laboratory studies in the ED revealed a normal creatine kinase (CK) level and amylase. Glucose was 224, the electrolytes were unremarkable, and the creatinine was 0.8. Her bicarbonate levels were low at 10.6; the calculated anion gap was 25. The patient had a normal lactic acid level and a normal lipase level. The complete blood count (CBC) was unremarkable, and so were the liver function test (LFT)s. A formal arterial blood gas (ABG) showed a potential hydrogen (pH) of 7.3, partial pressure of carbon dioxide (CO2) (PCO2) of less than 19, partial pressure of oxygen (PO2) of 135, and arterial bicarbonate unable to be calculated. The chest x-ray showed no infiltrates and was interpreted as normal. The ED contacted the intensive care unit (ICU) for admission with concern for DKA. The patient received intravenous (IV) fluids and was started on an insulin drip.
The ICU note states they were called due to the patient suspected of DKA. On reassessment, the patient had a normal temperature, heart rate of 107, and blood pressure was 151/101. Blood glucose had decreased to 146. Urinalysis showed no evidence of a urinary tract infection (UTI). The ICU team ordered a beta-hydroxybutyrate level and continued the fluids and insulin drip. The anion gap measured at 7. The patient was transitioned from insulin drip to glargine with lispro for prandial use. The internal medicine team assessed the patient; she was being transitioned out of the ICU and commented on reestablishing an insulin regimen before discharge.
The medical team noted she had an upcoming endocrinology appointment. At this point, the patient was discharged home.
At issue is the medical necessity of the Hospital Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Hospital Admission was medically necessary for this patient.
The presentation described a patient who arrived at the hospital with blood glucose values greater than 200, a beta-hydroxybutyrate of 4.1, and an elevated anion gap at 25, consistent with diabetic ketoacidosis. This complex condition requires continuous insulin infusion, frequent Accu-Cheks, adjustments of fluids, and subsequent transition to a subcutaneous regimen. Typically, the patients are treated with continuous insulin for 24 hours to calculate insulin requirements. This is particularly true in patients whose outpatient regimen remains unclear, as in this presentation. The patient had run out of medications and was generally using a combination of medications that inadequately controlled her blood glucose values. With such an elevated anion gap, this condition is generally treated in an intensive care unit.
Therefore, the requested health service/treatment of Hospital Admission was medically necessary.