Insulin-dependent Diabetes Mellitus in a 12yo.

Submitted by John T. Eanes II 
Medical Director, Utilization Management/Case Management, Children's Healthcare of Atlanta 

Denial Type: Level of Care
Insurance: Medicaid Replacement (MCO)
Reason for Being Hospitalized: Diabetic ketoacidosis

Hospital Course:

This is a 12 yo with type I insulin-dependent diabetes mellitus and acquired autoimmune hypothyroidism who was admitted with hyperglycemia, abdominal pain, headache, and diarrhea. Her initial laboratory valued included a blood gas with pH of 7.24 and HCO2 of 13, glucose of 515, and urinalysis with 2+ ketones. Based on these labs, the patient met criteria for Critical Level of Care for diabetic ketoacidosis with all interventions according to the evidence-based guidelines used by the payer.

Appeal Strategy:

We concentrated on the guidelines and contractual obligations reinforced by medical documentation; ensure understand state rules and contract language.