Diagnosis: Diabetic ketoacidosis
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This is a child with a history of type 1 diabetes who presented to the emergency department with abdominal pain and vomiting. He was lethargic on examination. He was tachycardic and tachypneic. His blood sugar was 437 with a pH (potential of hydrogen) of 7.34 and a beta hydroxybutyrate of 2.17 with an anion gap of 25 and a bicarbonate of 18 and a lactate of 5.6. Osmolality was 309. He was started on ceftriaxone and insulin. The patient's acidosis improved over the next 2 days. The patient was able to tolerate oral intake over the next 2 days. The patient's insulin regimen was reinstated appropriately.

Hospitalization for diabetic ketoacidosis is universally medically necessary. Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require intensive care unit (ICU) level care until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care. Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with q (every) 1 hour blood draws and nursing rules. The patient was admitted for treatment of diabetic ketoacidosis. The patient had hyperosmolality as well as mild DKA and dehydration from these conditions as well as gastroenteritis. The patient was appropriately admitted and treated with intravenous hydration, insulin, antibiotics, and monitoring. The requested admission is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient hospital admission is substantiated.