Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overdose
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female teen with medical history significant for cannabis use disorder, adjustment disorder with depressed mood, disruptive mood dysregulation, self-harming behavior, and possible major depressive disorder. She presented to the ED (emergency department) after having ingested an unknown amount of risperidone in an attempt at suicide six hours earlier.

The patient's vital signs included temperature 97.8, heart rate 132, respiratory rate 18, and blood pressure 126/87. She was noted to be somnolent. Lab work was obtained including toxicology, an electrocardiogram was obtained read as normal by the on-call cardiologist, and Poison Control was contacted with recommendations for admission for observation. Concerns included cardiac arrhythmia, hypotension, somnolence, extrapyramidal symptoms, and neuroleptic malignant syndrome. She was admitted to the PICU (pediatric intensive care unit). Admission orders included 1:1 observation, monitoring for complications of the ingestion, continuous cardiopulmonary monitoring, IV (intravenous) fluids at 1.5 maintenance, repeat lab studies including creatine kinase, Social Work consultation, and Psychiatry consultation.

Approximately twelve hours after the ingestion, the patient remained somnolent but denied suicidal/homicidal ideation, serial electrocardiogram studies were normal, and labs were unremarkable. She was evaluated by Psychiatry, with recommendations to restart her risperidone routinely at night and refer to outpatient mental health services. Inpatient psychiatric admission was not deemed necessary. After having been cleared medically and by Psychiatry, as she was preparing to discharge home, she had an episode of suspected dystonia with retrocollis and oculogyric crisis while remaining fully conscious and able to follow commands.

The discharge was canceled, and the patient returned to continuous cardiopulmonary monitoring and neurochecks every two hours. She did well overnight with no further episodes of dystonia. She was deemed stable for discharge with appropriate outpatient follow-up.

No, the Inpatient admission was not medically necessary. The patient could have been safely managed at lower level of care such as observation.

Risperidone is an atypical, or second-generation, antipsychotic that is used for both psychotic and non-psychotic disorders such as disruptive disorders. The main features of acute toxicity include tachycardia and dystonic reactions, with other cardiac and neurologic reactions less likely. Extrapyramidal symptoms may be severe, typically resolving following treatment with an anticholinergic agent. For patients with acute toxicity, recommendations include observation following extrapyramidal symptoms in case of recurrence. Overall, outcomes from overdose are typically favorable, with minimal risk of major toxicity.

In the case of this patient, she had been observed in the hospital setting following her ingestion of an unknown amount of risperidone and was preparing for discharge when she developed an acute dystonic reaction. She remained in the hospital overnight for further monitoring with no recurrence of dystonia. The care that the patient was given, including continuous cardiopulmonary monitoring and frequent neurologic evaluation, did not merit acute inpatient hospitalization. She could have been safely managed at lower level of care, including the overnight stay after the acute dystonia.