Diagnosis: Chest pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld.

This patient is a male with a history of diabetes, coronary artery disease, ectatic aorta, anxiety, depression, chronic obstructive pulmonary disease (COPD) and chronic opiate use for chronic back pain who was seen in the Emergency Room (ER) with a complaint of chest pain. In the ER, the patient's blood pressure was 156/93, his temperature was 98.2, his pulse rate was 111, and his respiratory rate was 20. He appeared agitated. His blood urea nitrogen (BUN) was 19, his sodium level was 135, his creatinine was 1.1, his glucose was 557, his anion gap was elevated at 17 with a lactic acid of 7, and a venous blood gas pH was 7.37. Troponin levels were negative. It was planned to admit the patient; however, he left the hospital against medical advice. The insurer denied coverage for inpatient hospital admission.

The case and the labs have been reviewed. Calculation of the patient's plasma osmolarity was 307.73. It is not sufficient for a diagnosis of hyperglycemic hyperosmolar state in which the plasma osmolarity should be >320 mOsm/kg. The patient also was not in diabetic ketoacidosis, as his venous blood gas pH was 7.37.(1,2) His lactic acid was high, suggesting lactic acidosis due to dehydration. That suggests the need for ER care for intravenous (IV) fluid and insulin for a few hours and follow-up as an outpatient.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. Based on the above, the medical necessity for the inpatient hospital admission from is not substantiated. The insurer's denial is upheld.