Diagnosis: Diabetic ketoacidosis (DKA).
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission. The denial is overturned.

The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD). He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.

Vital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.

White blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.

Chest x-rays revealed (CXR) revealed B/L airspace disease.

The patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx).

Repeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.

The patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.

This patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation. Based on above, it was appropriate to admit this patient to the hospital for active treatment and very close monitoring. This patient was not stable to be treated in any other setting.

This patient decided to sign out against medical advice (AMA), which was not in any one's control. He was not stable at the time he absconded from the hospital.

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 inpatient hospital admission is overturned. Medical Necessity is substantiated.