Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ingestion Of Unknown Quantity Or Type Of Pills 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is upheld. 

No, the Inpatient admission was not medically necessary. 

The patient is a female child that was taken to the ED after her father found her on the floor with a white tongue, pill on her lips, a couple pills in her hand and more than a dozen pills that she had taken out of a napkin on the floor. An ACS (Administration for Children's Services worker was at the home at the time. The father described the patient as staring at the ceiling for several minutes. The father had never seen the pills before, but recalled that his wife was taking Maca pills for appetite. He was concerned because he thought some of the mother's friends might take pills. The mother said that they were sugar pills for teething. 

In the ED, the child was back to her usual self. Vital signs included temperature 37, heart rate 122, and respiratory rate 22. Her examination was unremarkable. Poison Control was contacted and work-up was recommended, followed by 24-hour observation and monitoring. Laboratory evaluation revealed normal glucose, elevated AST (aspartate aminotransferase) (157), elevated direct bilirubin (1.3), elevated alkaline phosphatase (267), and mild metabolic acidosis (CO2 [carbon dioxide] 21). Alcohol, acetaminophen, and aspirin were all negative. 

The patient was admitted to the pediatric floor for ingestion of unknown tablets, quantity unknown, possibly teething tabs. Admission orders included regular diet, routine vital signs, and repeat labs. She did well overnight. ACS was contacted about the admission, and the family was counseled about storing medications. The patient was deemed stable for discharge following social services clearance. 

Pediatric pharmaceutical ingestions represent a significant cause of morbidity. In children under five years of age, ingestion generally is unintentional and results from unsafe storage. If the ingested medication cannot be identified, then it must be considered potentially fatal. There are specific adult medications that may be lethal in children, including tricyclic antidepressants, chloroquine calcium channel blockers, opioids, amphetamines, propranolol, and theophylline. While attempts must be made to identify the ingested medication, the child must be observed in the hospital for any signs of developing toxicity, typically a minimum of twelve hours. In general, early recognition with prompt initiation of appropriate supportive care results in good outcome. 

In this case, the child was found with pills of unknown origin in her mouth, in her hand, and on the floor. The mother reported that they were teething tablets, but because there was no bottle or identifying marks, Poison Control recommended laboratory evaluation and overnight observation. While a period of monitoring in the hospital was reasonable and appropriate, the child was overall neurologically appropriate and hemodynamically stable. She did not require acute inpatient admission. She could have been safely managed at a lower level of care, such as observation.