Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal- Possible ingestion.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Admission. 
The denial is upheld. 

The patient is a male child with a medical history significant for asthma, allergies, and non-verbal autism that was taken to the emergency department (ED) via Emergency Medical Services (EMS) for evaluation of possible ingestion. His father found him with a 7-day pillbox of bupropion 300 milligram (mg) pills, with unknown amount missing. Approximately three hours had passed before he was found with the pill box. He was taken to his primary care practitioner where he was evaluated and sent to the ED for further management. The child had no constitutional symptoms or unusual behavior. Examination was significant for crying in his father's arms, moist mucous membranes, tachycardia with regular rhythm, and non-focal neurologic exam. Vital signs included a heart rate at 153, respiratory rate was 26, and temperature was 36.7. Poison Control was contacted with recommendations for 24 hours of monitoring including cardiorespiratory monitoring, electrocardiogram every six hours, and activated charcoal. These recommendations were implemented, and lab studies were ordered, significant for carbon dioxide (CO2) at 19, and a normal troponin. He was given a normal saline bolus prior to transfer to the floor. Admission orders included the Poison Control recommendations as well as Ativan as needed for seizure activity, intravenous (IV) fluids, vital signs every two hours, and social services consultation. He slept well overnight, tolerating a diet for his age, with no seizure activity. He was given a second IV fluid bolus for borderline blood pressures. An electrocardiogram (ECG) obtained at 0100 hours revealed sinus arrhythmia and corrected QT interval (QTc) 440 milliseconds (ms). Repeat ECG at 0630 also revealed a borderline QTc. Final ECG at 1300 hours revealed normal QTc 435ms. Social services submitted a report to Administration for Children's Services (ACS), and discharge was held pending ACS clearance. He was discharged home with his mother following completion of parent interviews and social clearance.
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.
Bupropion is a medication taken to treat depression and anxiety. Accidental ingestion occurs typically in children under the age of six years. Symptoms range from sinus tachycardia, nausea/vomiting, hyperactivity to seizures, hallucinations, and hypertension. According to the literature, accidental pediatric bupropion ingestion rarely results in clinical effects that require medical intervention.
This young child with autism, asthma, and allergies was brought to medical attention after potential accidental ingestion of bupropion 300 mg pills. He was treated with activated charcoal and IV fluids in the ED and per Poison Control recommendations, admitted for observation, cardiac monitoring, and serial electrocardiograms. He remained stable throughout his hospital stay, receiving a second bolus of IV fluids for borderline blood pressures. While it was appropriate and medically necessary to monitor this child in the hospital per Poison Control recommendations, he was overall hemodynamically stable and remained in the hospital following medical clearance pending clearance by children's services. He did not experience hypertension, vomiting, or seizures. He did not require an inpatient admission.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary.