Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ingestion of toxic substance
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male child that presented to a community ED (emergency department) after having ingested a laundry detergent pod. He vomited three times prior to presenting to the ED (emergency department), and he was noted to be drooling upon arrival. He had no signs of breathing difficulty.

The patient's initial vital signs included temperature 35.8, heart rate 147, and respiratory rate 23 with 100% oxygen saturation in room air. Examination was notable for posterior oropharyngeal erythema without uvular swelling, drooling, and unremarkable respiratory exam. He was treated with an IV (intravenous) fluid bolus. Poison Control was contacted with recommendations for Gastroenterology consultation and monitoring for "respiratory collapse." Laboratory evaluation was significant for WBC (white blood cell) count 15.8K (thousand) and CO2 (carbon dioxide) 18. He was transferred to a children's ED (emergency department) for further evaluation. His vital signs included temperature 37, heart rate 147, and respiratory rate 24 with 100% oxygen saturation in room air.

The patient's examination was significant for fussy but in no acute distress, mild erythema around the lips, moist mucous membranes, no active drooling, no visible oral injuries, mildly erythematous oropharynx, clear lungs, benign abdomen, and non-focal neurologic exam. Consultations were requested from ENT (otolaryngology) and Gastroenterology. Recommendations included admission for endoscopy 12-24 hours post-ingestion. He was subsequently admitted to the Telemetry floor for continuous pulse oximetry. Admission orders included nothing by mouth, maintenance IV (intravenous) fluids, close monitoring for airway compromise, and follow-up of ENT (otolaryngology) and Gastroenterology consultations.

The patient was evaluated by ENT (otolaryngology) with fiber-optic nasopharyngolaryngoscopy within normal limits, no lesions or edema. He was also evaluated by Gastroenterology with recommendations to start trial of a clear liquid diet, no need for endoscopy if he tolerates his diet, and then advance his diet as tolerated. He had no further episodes of vomiting, no difficulty breathing, and was able to tolerate his advancing diet. He was deemed stable for discharge.

Yes, the Inpatient admission was medically necessary.

Liquid laundry detergent capsules or pods have become increasingly popular in the home. They contain multiple substances, including anionic surfactants, non-ionic surfactants, propylene glycol, and ethanol. Toxicity is by way of the non-ionic surfactants. Ingestion is the most common form of exposure, although skin and eyes may also be affected. Following ingestion, vomiting is most common. Additional features include coughing, drowsiness, respiratory depression, central nervous system depression, esophageal or gastric injury, metabolic acidosis, and death. With eye exposure, conjunctivitis is most common, less likely to sustain corneal injury. Skin toxicity is rare, although there is possibility of skin burns with prolonged contact. Management of ingestion is supportive. Gut decontamination is not recommended. Supplemental oxygen may be needed as well as bronchodilators for laryngospasm, and intubation for central nervous system and respiratory depression. For patients with drooling or oropharyngeal burns, endoscopy is necessary to identify the extent of the injury. MRI (magnetic resonance image) may be needed in the presence of substantial mucosal damage.

This young child presented to the ED (emergency department) after biting into a laundry detergent pod. He vomited multiple times and was drooling upon presentation to the ED (emergency department). He was noted to have oropharyngeal erythema as well as mild erythema around his mouth. He was admitted for close monitoring because of concern for significant injury given his physical exam findings. Both ENT (otolaryngology) and Gastroenterology were consulted for recommendations and endoscopy. ENT (otolaryngology) performed bedside fiber-optic nasopharyngolaryngoscopy with no evidence of injury. Gastroenterology recommended trial of clear liquids before determining need for endoscopy. Because the child was able to tolerate his advancing diet, he was deemed stable for discharge. However, with his clinical presentation and potential for significant and serious injury, his hospitalization was most appropriate and consistent with acute inpatient care.