Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for depression on Prozac who was transferred from outside hospital for evaluation and management of suicide attempt the prior night. He reported that he took Prozac 20 milligrams (mg) unknown amount, ibuprofen 800 mg times (x) 8 tablets and 200 mg x 10 tablets. He also reported that he took oxycodone 6 tablets and another pain relief medicine that he thinks maybe Tylenol on the night prior to admission. Prior to presentation, he experienced nausea and several episodes of non-bloody, non-bilious (NBNB) emesis along with lightheadedness and blurry vision. The patient denied previous suicide attempts.
In the emergency room (ER), he received fluid resuscitation and magnesium (Mg) sulfate for a non-specific ST abnormality and elevated QTc. Liver enzymes were marginally elevated (aspartate aminotransferase (AST) 65, alanine aminotransferase (ALT) 48) with an acetaminophen level of 27, so he was started on N-acetylcysteine protocol per toxicology recommendations. Following his 4 hour bag of N-acetylcysteine, repeat liver function tests (LFTs) and acetaminophen showed stable LFTS (AST 57, ALT 49) and acetaminophen level of 5.3. A 16 hour bag on N-acetylcysteine was not initiated. On admission exam, the blood pressure was 130/68, pulse 64, respirations 18, and oxygen saturation (O2 sat) 100%. There were no abnormalities reported on physical exam. Assessment on the admission history and physical report was a male with past medical history significant for depression on Prozac transferred from an outside hospital for evaluation and management of suicide attempt last night. Upon assessment by toxicology, the patient showed no signs of distress, no nausea, vomiting, no pain and the physical exam was normal. The patient's electrocardiogram (EKG) was normal of then sinus bradycardia which was most likely due to an athletic lifestyle. The patient did not display serotonin syndrome manifestations. No central nervous system (CNS) or respiratory depression was present and there was no further concern for oxycodone toxicity. Ibuprofen likely caused nausea and vomiting but there were no concerns for continued toxicologic affect.

Aspartate aminotransferase (AST) elevation likely coincided with muscular creatine kinase (CK) elevation in this work up with less likely primary liver ideology causation. The plan was to repeat an acetaminophen level, CK, AST and ALT. If undetectable and liver functions were improving the N-acetylcysteine could be stopped and the patient could be cleared from a toxicology perspective. He was evaluated by the psychiatry team who felt that his ingestion was impulsive and determined that he was not a safety risk. They recommended increasing Fluoxetine to 40 mg. He was cleared for discharge from both psychiatric and medical perspectives. He was discharged with instructions to call his primary medical doctor (PMD) to schedule an appointment and also an appointment was scheduled for him to follow-up (f/u) with psychiatry in 2 days.

The health plan's determination is upheld.

The requested service/treatment of inpatient hospital admission was not medically necessary for this patient. This patient presented with a suicide attempt after ingestion of multiple tablets of different types including Tylenol, Prozac, Ibuprofen and oxycodone. He was evaluated by psychiatry and inpatient psychiatric care was not recommended. He was evaluated by a toxicologist who did not feel he had any signs of distress or impending decompensation from his ingestion. At the time of admission, his exam was normal and his vital signs were essentially stable apart from intermittently elevated blood pressure. His liver function tests as well as his acetaminophen levels trended down appropriately so that he did not require his final 16 hour bag on N-acetylcysteine. He was cleared within 18 hours of admission for discharge home. Per the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 22nd edition for Pediatric drug ingestion or overdose, the patient did not meet any criteria for inpatient level of care. He did not have any hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, severe electrolyte abnormalities, altered mental status that was severe of persistent, specific finding indicating severe, prolonged or delayed drug toxicity, no metabolic findings too severe for observation care treatment, no toxic drug levels that persisted or necessitated ongoing treatment, recurrent seizure, suspected abuse or neglect or psychiatric risk status not acceptable for outpatient management. For these reasons, inpatient level of care was not medically necessary for this patient.