Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tylenol Overdose.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who presented to the emergency department (ED) after ingestion 32 grams (g) of acetaminophen about an hour prior to arrival as an attempted suicide. She also used a razor to inflict superficial wounds on her arm and neck. She vomited several times while in the ED and reported a headache rated 6-7/10 and dizziness. The one-hour level was 164. Poison Control was contacted with recommendations to check labs, administer activated charcoal as soon as possible, check acetaminophen level four hours after ingestion, initiate intravenous (IV) N-acetylcysteine (NAC) protocol, and recheck labs before the third bag of NAC was done. She was admitted to the Pediatric Intensive Care Unit (PICU) for ongoing management.
 Admission orders included cardiorespiratory monitoring, liquid diet and advance as tolerated, saline lock, strict input/output, IV NAC per protocol, gastrointestinal (GI) protection with histamine (H2) blocker, repeat lab studies including acetaminophen level, continued consultation with Poison Control, frequent abdominal assessment, 1:1 watch with suicide precautions, and Psychiatry consultation. She was evaluated by psychiatry with additional history notable for a diagnosis of major depressive disorder, recent sexual assault, history of self-harm with cutting, history of multiple suicide attempts, and no inpatient admissions or medication trials. The recommendations included inpatient psychiatric admission once medically cleared. She completed the full course of NAC.  She was medically cleared for transfer to inpatient psychiatry with ongoing 1:1 watch with suicide precautions. At issue is the medical necessity of an inpatient stay.

Given the severity of the suicide attempt, acute inpatient admission was medically necessary and appropriate. A lower level of care would not have been sufficient or safe in this case.
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 course of therapy.
This female with a history significant for major depression, self-harm, and multiple suicide attempts presented to the ED after taking a very large amount (32gm) of acetaminophen in another attempted suicide. Initial acetaminophen level was elevated at 164, necessitating contact with Poison Control and subsequent initiation of treatment with activated charcoal and IV NAC (per protocol). She was evaluated by Psychiatry and assessed to be at high risk for self-harm, with recommendations to transfer to inpatient psychiatry as soon as deemed medically stable. Upon completion of the NAC protocol, with acetaminophen level of 5, she was medically cleared. Given the serious nature of her suicide attempt and the potential for significant morbidity including death, acute inpatient admission and management was medically necessary and appropriate. A lower level of care would have inappropriate in this situation.