Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis (DKA).
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This is a female patient with a diagnosis of type 1 diabetes mellitus and median arcuate ligament. She presented to the Emergency Department (ED) with complaints of persistent nausea, bilious emesis, and abdominal pain. In the ED, the patient had tachycardia of 112 beats per minute (bpm). She was given pain medications, anti-nausea medications, and intravenous (IV) fluids. Laboratory testing revealed high anion gap metabolic acidosis, and elevated beta-hydroxybutyrate. The patient was admitted to the Medical Intensive Care Unit (MICU) for diabetic ketoacidosis (DKA). In the MICU, the patient was started on insulin drip and subcutaneous Heparin. A chest X-ray showed trace left side apical pneumothorax. The plan was for an Endocrinology evaluation, however, the patient decided to leave Against Medical Advice (AMA). The patient was recommended to follow-up with her Endocrinologist, to be compliant with her insulin regimen, and to return to the ED in case of worsening of symptoms or poorly controlled blood glucose levels.

"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 ...Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis" (Gosmanov, A.R. et al. 2018).

"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..." (Fayfman, M. et al. 2017).

Based on the medical facts from the available records, claim documentation, and any additional information obtained from the claimant's treating provider(s) from the perspective of Endocrinology, Diabetes, & Metabolism/Internal Medicine, the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient, as the inpatient hospital admission would be considered medically necessary for this patient. She met diagnostic criteria for DKA and American Diabetes Association hospital admission guidelines. 

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 hospital admission is overturned. Medical necessity is substantiated.