Diagnosis: Diabetes
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

This is a patient with a history of type 1 diabetes. She presented to the emergency department with hyperglycemia, weakness, vomiting. Glucose levels at home were in the 300s. She woke up feeling weak and had 2 episodes of non-bloody nonbilious vomiting. The glucose meter read High. Her mom took off the insulin pump and administered 22 units of Lantus and 5 units of rapid acting insulin at 6 AM. Serum glucose was 341. Ketones were greater than 160. Anion gap was 17. pH (potential hydrogen) was 7.25 with a bicarbonate of 11. Repeat anion gap was 24. She was treated with a normal saline bolus. The patient developed hypoglycemia with a glucose of 67. She was started on dextrose. Her repeat blood gas demonstrated resolution of diabetic ketoacidosis (DKA). The patient received blood glucose monitoring every hour. The patient was discharged.

Hospitalization for DKA is universally medically necessary. [1-9] Patients with diabetes and DKA initially generally require intensive care unit (ICU) level care [1],[3],[4],[5] until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care. [10],[11] Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with every 1 hour blood draws and nursing rules. The patient was admitted for treatment of DKA.

The patient's DKA resolved with insulin treatment and the patient developed hypoglycemia which was also treated. Discharge from the emergency department was not appropriate. A lower level of service such as observation is not appropriate given the complexity of treatment required for DKA. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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 admission is overturned. Medical Necessity is substantiated.