Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Accidental Overdose
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient was transferred from an outside hospital emergency room (ER) with her mother for accidental ingestion of Verapamil extended release (ER). The patient is an active child and her mother reported that she pulled down her pill bottle and when she turned around she saw that she had one verapamil capsule in her mouth and some on the floor. The mother was unsure if the patient swallowed any or how much. She was brought to an outside hospital ER where she was given a normal saline (NS) bolus and charcoal. She received another dose of charcoal in the accepting ER as well as an electrocardiogram (EKG). The EKG showed normal sinus rhythm. The patient tolerated a bottle in the ED without emesis. Poison control was consulted who recommended monitoring for 24 hours. Her vital signs in the ER and after admission to the floor for observation remained stable. The following morning her mother reported she was at her baseline neurologically. She was taking adequate by mouth (PO) with good urine output. The patient was admitted for accidental ingestion of Verapamil ER. She was monitored without event. Poison control was re-consulted the morning after admission and she was then cleared. She had no complications or issues and was safely discharged home.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of Inpatient Hospital Admission  was not medically necessary for this patient.
She patient presented with suspected ingestion of an unknown amount of Verapamil ER. She was brought to the ER where she was given activated charcoal and a normal saline fluid bolus. Poison control was called and their recommendation was to monitor the child for 24 hours post ingestion. Current recommendations support monitoring for 24 hours for accidental ingestion of extended release formulations of Verapamil. Concerns would be altered mental status and/or lethargy, hypotension, bradycardia, heart block, vomiting and even death. The patient had a normal EKG, normal mental status, no vomiting, was tolerating PO and had stable vital signs. Monitoring vital signs and mental status for any of these changes would not require inpatient level of care.
A lower level of care while assessing the need for additional care or readiness for discharge would be adequate care for this patient. Per InterQual criteria for general pediatrics, a lower level of care is warranted for toxic exposure if patient clinically stable, unknown type or quantity of substance, and assessment or monitoring needed at least every 4 hours. Inpatient level of care would be warranted for agitation or ataxia, abnormal blood gas, disorientation, increasing irritability, increasing lethargy, protracted vomiting, oxygen saturation (O2 sat) less than (<) 93% with bradypnea or tachypnea, toxic level of substance, abuse or neglect suspected, antiemetic greater than or equal to (>/=) to 3 times (x) in 24 hours, requiring supplemental O2, bronchodilator or corticosteroid. This patient did not meet any criteria for inpatient level of care therefore, this level of care was not medically necessary for this patient.