Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health
Treatment: Inpatient hospital stay

Diagnosis: Mental Health-Other- Suicide attempt/Tylenol Overdose
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld the health plan's denial in whole.

The pediatric patient has medical history significant for asthma that presented to the emergency department (ED) with vomiting following acetaminophen ingestion. According to the parent, she was having menstrual cramps the night before and took ten tablets of acetaminophen 650 milligrams (mg) at approximately 0300 hours. She subsequently developed mid-upper abdominal pain and vomiting. She denied taking the acetaminophen as an attempt at suicide, but her mother was concerned about depression.
She was treated with a normal saline bolus and a dose of Zofran with improvement in her distress. She reported ongoing chest pain with hyperventilation. Poison Control was contacted with no recommendations for Mucomyst or repeat labs. She was admitted to the Pediatric Intensive Care Unit (PICU) for further management. Admission orders included continuous cardiorespiratory monitoring, regular diet, maintenance intravenous (IV) fluids, Zofran as needed, 1:1 observation, and Child Psychiatry consultation. Child Psychiatry consultation was obtained, and during the interview she acknowledged that the ingestion was her second impulsive suicide attempt, the first she never disclosed. She was not actively suicidal. Recommendations included 1:1 monitoring, consideration for antidepressant medication, and acute psychiatric hospitalization once medically cleared. She did well overnight, was asymptomatic, and tolerated a regular diet. She was declared medically stable the next day. She was subsequently transferred to the pediatric floor pending placement. While awaiting psychiatric bed availability, she was started on escitalopram 5 mg. Direct 1:1 observation continued while Social Services located an appropriate facility. She was subsequently discharged for transfer via ambulance and admission to a Pediatric Psychiatry facility.

Inpatient hospital admission was not medically necessary for this patient.

Acetaminophen overdose is one of the more common means for attempting suicide, and if not recognized early can have dire and sometimes fatal consequences. The most important intervention following early recognition is prompt treatment with Mucomyst (N-acetylcysteine, NAC) to prevent liver injury. There is a nomogram available to guide management, and Poison Control can also be an invaluable resource for determining the course of therapy.
This female teen with history of asthma ingested ten acetaminophen tablets (total 6.5 grams (gm)) in a suicide attempt. She had a previous undisclosed attempt a year prior. She was not under the care of a psychologist, counselor, or therapist. Her acetaminophen level and liver function/enzymes were not sufficiently concerning to merit treatment with NAC, but her two suicide attempts raised concern for ongoing danger to self. Psychiatry recommendations included starting an antidepressant and admission to an inpatient psychiatric facility once medically cleared. She was medically cleared the day following admission but there was no appropriate placement available. She was discharged and transferred as soon as there was bed availability.
While it was reasonable and appropriate to monitor this patient in the hospital pending bed availability for their own safety, they were overall hemodynamically stable with no ongoing abdominal pain or vomiting and no significant metabolic abnormalities. She did not require acute inpatient admission and could have been safely managed at a lower level of care.