Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ingestion of Foreign Object (9 magnets)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a  male. He presented to the ED (emergency department) after having ingested 9 magnets at home. He was without abdominal pain, nausea, or vomiting at presentation. He was admitted to the hospital. His past medical history was significant for Chiari malformation. The patient had normal vital signs. He was evaluated with x-ray and CT (computed tomography) scan of the abdomen and pelvis that showed the metallic foreign bodies within the bowel.

The patient was initially treated with NPO (nothing by mouth) status and IV (intravenous) fluid. X-ray showed progression of the magnets within the small bowel. He was treated with Golytely and Senna. Day three, x-ray showed the magnets in the right lower abdomen. Day four, the patient underwent surgery (enterotomy, appendectomy and drainage of the right 4th digit paronychia).

Day five, the patient was started on a clear liquid diet. He tolerated the diet and oral medication and was considered to be stable for discharge.

The health plan denial letter states that the patient ingested 9 magnets and underwent surgery (laparoscopic enterotomy, appendectomy and drainage of the right 4th digit paronychia). There were no complications and the patient was discharged home. There was no documented hemodynamic instability, bowel obstruction, ascites, elevated bilirubin or ileus. This letter references InterQual  Acute Pediatric General Medical.

Yes, the Inpatient admission was medically necessary.
The records support that inpatient admission was medically necessary, appropriate and consistent with the generally accepted medical standards.

The submitted records support that this patient presented to the ED (emergency department) after having ingested 9 magnets at home. The presence of these ingested magnets was confirmed with x-ray and CT (computed tomography) scan. Based on this presenting condition it was appropriately anticipated that he would require serial examination, follow up imaging and possible surgery for the condition of retained foreign bodies that would span a period of at least 48-hours. Ingestion of multiple magnets is known to result in acute small bowel obstruction. He was admitted and was treated with NPO (nothing by mouth) status and laxative medication. He was followed with repeat imaging that showed progression of the magnets within the bowel, but failure to pass into the colon. He underwent surgery. While his post-surgical course was uncomplicated and he was able to be started on a liquid diet, he was appropriately discharged from the hospital once he demonstrated tolerance of oral intake.

Inpatient admission for the condition of ingested foreign bodies (magnets) and clinical concern for intestinal obstruction was consistent with medical standards as the period of inpatient confinement was anticipated to last more than two days. There was a high index of suspicion that intervention would be required, the patient required NPO (nothing by mouth) status and provision of IV (intravenous) fluid. His evaluation required that he not eat or drink for an extended period (more than 24 hours). The care that was medically necessary for this patient was not within scope of observational care. His clinical condition was most appropriately managed with an inpatient level of care.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
As stated above inpatient stay was medically necessary for this patient.

The medical records support that this patient presented to the ED (emergency department) with multiple ingested magnets. His clinical condition and the need for close clinical follow up including examination, labs, and imaging was consistent with an inpatient designation. He did require surgical intervention as was performed following a period of non-operative therapy.

The patient was appropriately evaluated for his presenting condition and treated with IV (intravenous) fluid, NPO (nothing by mouth) status, laxative medications, and surgery. He was appropriately monitored with imaging, lab data, and follow up clinical assessment during his inpatient confinement. An inpatient level of care was consistent with standards of care.