Diagnosis: High blood sugar.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is overturned.

This is a male patient.

The patient has a history of type I diabetes complicated by multiple prior ICU admissions for diabetic ketoacidosis, ADHD and asthma. The patient was brought by medics for worsening nausea, vomiting, abdominal pain, lightheadedness, with a glucose at home in the 500s. The patient admitted to nonadherence with outpatient medications due to running out of insulin. Pulse was 138. Respiratory rate was 21. Blood pressure was 98 /63 Mucous membranes were dry. His abdomen was tender. PH was 7.51. Potassium was 2.7. Phosphate was 1.6. Magnesium was 1.1. All were low. Glucose was 251. Beta hydroxybutyrate was 1.99.

In the emergency department, the patient was treated with intravenous fluids, magnesium, phosphorus, potassium. The patient's mother reported that she was unable to pay for his medications because his insurance was not active.

A note reports that the patient was on fluids. Glucoses overnight were reported to be in the 500s. The morning potassium was still low at 2.9 as were the magnesium and phosphorus. He continued on Lantus and Humalog. The Lantus dose was increased. IV fluids were continued for hypokalemia, low magnesium and phosphorus. Magnesium, potassium, phosphorus were also supplemented separately.

A reports that the blood sugars have been trending down in that his appetite is good. His potassium was still low at 2.9. Phosphorus was normal. Magnesium was still low at 1.3. IV fluids with potassium were continued. Potassium phosphorus and magnesium were supplemented. His Lantus was increased to 30 units. Given the continued electrolyte abnormalities the patient was supplemented, and labs were to be drawn.
The potassium normalized to 3.7. Magnesium remained low at 1.3.

The patient was deemed safe for discharge.

Yes. Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state [1], [2], [3], [4], [5], [6] or ketosis with other findings requiring inpatient admission [7], [8], [9]. The patient presented with severe hyperglycemia, vomiting, ketosis and severe electrolyte abnormalities with hypokalemia hypo-magazine and hypophosphatemia. Discharge from the emergency room would have been unsafe.

Inpatient treatment to clearly ketones and to replete the electrolyte abnormalities was necessary. The patient continued to have severe hypokalemia until the day of discharge. The patient hypokalemia was appropriately treated. The patient was unsafe for discharge. The requested acute inpatient admission was medically necessary in its entirety with discharge.