Diagnosis: diabetic ketoacidosis
Treatment; Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a male with past medical history of type one diabetes, coronary artery disease (CAD) / coronary artery bypass graft (CABG), and seizure disorder, who presented for abdominal pain and hyperglycemia. Review of system was negative for additional clinical symptoms. The patient was admitted for diabetic ketoacidosis.

The inpatient admission was medically necessary. The care could not have been safely rendered at a lower level.
The documentation supports the inpatient level of care based on the presence of clinical signs and symptoms consistent with dehydration and Diabetic Ketoacidosis (DKA). DKA can be a life-threatening medical emergency. The patient had a significantly elevated plasma glucose, decrease in serum bicarbonate, and an elevated anion gap. As such, inpatient level of care for intravenous (IV) fluids, electrolyte stabilization/monitoring and intravenous insulin were necessary for the entire length of stay. Without proper hydration and aggressive insulin treatment, patients can rapidly re-enter the DKA phase requiring intensive level of care or insulin drip and close monitoring. In this case, the patient had evidence of DKA, poorly controlled diabetes and associated hyperglycemic crisis. The Inpatient level of care is justified.