Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anticholinergic toxicity

Treatment: Inpatient hospital ancillary services

The insurer denied coverage for inpatient hospital ancillary services. The denial upheld.

This patient is a female with no significant past medical history  presented to the Emergency Department after ingesting an unknown number of 10 milligram Loratadine pills. Mother gave activated charcoal capsule to the child at home on recommendation from the poison center. Upon arrival temperature was 97 F, heart rate was 148 beats per minute, respiratory rate was 22 breaths per minute, and pulse oximetry reading was 99%. As per the ED note, patient did not have any altered mental status and not in distress.  Later on during the emergency visit the patient had a temperature of 100.6 F, a heart rate of 180 beats per minute, and a blood pressure of 120/39. Her cheeks were red and flushed. The patient's mother claimed that she was acting the same as she usually does. Poison control was contacted. They recommended obtaining an electrocardiogram, 6 hours of observation, and monitoring vital signs. They also recommended administering Physostigmine, which the pharmacy did not have in stock. The patient refused to take oral charcoal. An electrocardiogram showed sinus tachycardia. Blood gas showed a pH 7.4, bicarb 23 meq/L Labs revealed mild anemia, a lactate level of 3.5, and an elevated aspartate aminotransferase level. Complete blood count was within normal limits. In the emergency room the patient was given intravenous fluids and Acetaminophen. She was admitted to the Pediatric Intensive Care Unit for anticholinergic toxicity. The plan was to keep the patient on nothing by mouth, administer intravenous fluids, administer Ativan as needed, and monitor the patient for urinary retention. The patient was catheterized for urinary retention. The patient did not require any intervention other than IV fluids and Ativan as needed for agitation. Her vital signs, and her anticholinergic symptoms, particularly the heart rate improved. The clinical symptoms improved and patient was discharged on 3rd day.

The treatment of such a patient should be continued in the hospital. However, observational status would have sufficed. The patient developed anticholinergic toxidrome, which improved, as expected. One of the reassuring factors in this child were the exposure was unintentional and accidental. As one can imagine, a small children does not have the hand eye coordination to ingest multiple tablets of unpalatable loratadine. Hence the ingestion amount should be less than fatal dose. Furthermore, the poison center only recommended 6 hours of observation. There was no acidosis, ph 7.4 and bicarb was 23. There was no cardiotoxicity that needed sodium bicarbonate, or other antidotes such as lipid emulsion. She also did not need any pressor support nor any positive pressure for respiratory support. There is no published study of the fatal dose in pediatrics, however, there was a case report where a toddler ingested 300 mg of loratadine and patient did not have much toxicity and managed only with supportive care. Due to the above facts, inpatient level care exceeds the medical necessity of patient. The patient could have been managed in an observational status.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital ancillary services at the inpatient level of care is not substantiated.  The insurer's denial is upheld.