Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure Disorder/ possible overdose
Treatment: Inpatient Hospital/ Inpatient admission
The health plan has denied the inpatient admission as not medically necessary. The health plan's determination is upheld.

The patient is a male teen with a medical history of possible seizure disorder (two syncopal/seizure episodes) who was taken to the emergency department (ED) by Emergency Medical Services (EMS) following a possible overdose. The patient's father reported that there should have been fifteen Depakote (125 milligram (mg)) pills in the bottle, and he found only three. The patient reported taking two pills because he had forgotten to take his dose the night before. He denied suicidal ideation. He was overall asymptomatic. His vital signs were within normal limits. The physical examination was unremarkable. Laboratory testing was significant for glucose of 91, carbon dioxide (CO2) of 24.9, a white blood cell count (WBC) of 3.9 thousand (K) with 41.4% (percent) neutrophils, ammonia of 34, an aspartate aminotransferase (AST) of 15, an alanine aminotransferase (ALT) of 13, an alkaline phosphatase of 156, a valproic acid level greater than (>) 150 at 1337 (repeat levels were 204.5 at 1515 and 147.4 at 1802).
The patient was re-evaluated about an hour and a half after his initial examination and was noted to be sleepy but arousable with no nystagmus and normal gait. Poison Control recommended repeat levels every four to six hours to confirm decreasing serum levels. Psychiatry was also consulted, they were in agreement that the overdose was not intentional. He was evaluated several hours later, was able to ambulate and eat, and was completely asymptomatic. His father agreed that he was at baseline. However, his serum level was still super-therapeutic so he was admitted for overnight monitoring and serial blood levels. Additional valproic acid blood levels included 114 and then 84. Admission orders included a regular diet, an electrocardiogram, and serial valproic acid levels.
The patient remained stable overnight with no acute events. His repeat WBC count was 5.4K with 43.8% neutrophils, ammonia of 42, and a valproic acid of 57.6 and 52.2. The initial electrocardiogram was suspicious for left ventricular hypertrophy, and a repeat was suspicious for biventricular hypertrophy. By the afternoon, his valproic acid level was 44.9. He was subsequently deemed stable for discharge.

The inpatient admission was not medically necessary.
Valproic acid is a medication originally developed and used as an anticonvulsant. It is also used for a variety of psychiatric conditions as a mood stabilizer for example. Toxicity from overdose is characterized by central nervous system depression, with extreme manifestations including hyperammonemic encephalopathy and hepatotoxicity. When management is indicated, it might include gastric decontamination, L-carnitine for hepatic protection, extracorporeal removal, and administration of meropenem.
This young man took two pills in the morning because he had forgotten his dose the night before. He was initially asymptomatic, but, at some point, was noted to be sleepy. His valproic acid level was initially super-therapeutic over 150. Serial levels, as recommended by Poison Control, demonstrated normalization. He remained asymptomatic. While it was not unreasonable to monitor him in the hospital overnight until the drug level was less than 50, he did not require an acute inpatient admission. He was overall hemodynamically stable, with no evidence of impending respiratory failure, refractory vomiting, or severe central nervous system depression. He could have been safely managed at lower level of care.