Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is: Overturned, in whole.

The patient is a female with medical history of reactive airway disease who presented to the emergency department (ED) after ingesting an unknown medication. She was found chewing on a blue and white capsule, possibly clonidine or thiazide or duloxetine. It also could have been a medication belonging to one of the other adults. Half an hour later, she was sleepy, walking with an unsteady gait, and refusing to eat or drink. The mother attempted to induce vomiting, productive of a small amount.

Vital signs included a temperature of 36.5, heart rate 130, respiratory rate 26, and blood pressure 116/58. Examination was significant for moist mucous membranes, reactive pupils, regular heart rate, normal lung exam, regular heart rate and rhythm, benign abdomen, sleepy but moving all limbs and able to take a couple steps. Poison Control was contacted, with recommendations for labs, electrocardiogram, and hospital monitoring for 24 hours. Laboratory evaluation was significant for mild hyponatremia (sodium 134), elevated aspartate aminotransferase (AST) (72), elevated alkaline phosphatase (139), normal glucose, and normal venous blood gas. She was admitted for further management and monitoring of unknown ingestion. Admission orders included cardiopulmonary and neurologic monitoring, nothing by mouth, and intravenous (IV) fluids. She remained sleepy beyond 24 hours of ingestion, not back to baseline. Poison Control recommended ongoing monitoring until she was fully back to baseline. Her diet was advanced to clear liquids. More frequent glucose monitoring was done. Electrocardiogram was interpreted as normal. She remained stable and was discharged home. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is overturned in whole.

Pharmaceutical ingestions represent a significant cause of morbidity. In children, 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 monitored in the hospital for any signs of developing toxicity. In general, early recognition with prompt initiation of appropriate supportive care results in good outcome.
Duloxetine is a medication used to treat depression, physiologically a serotonin and norepinephrine reuptake inhibitor. Side effects of unintentional ingestion include tachycardia, nausea, vomiting, agitation/irritability, dizziness/vertigo, and drowsiness. Compared to older children, children under six years of age seem to have less likelihood of clinical effects. Overall, however, the majority of ingestions are considered benign and may be manageable without significant intervention.
In this case, the patient was found with a capsule in her mouth, suspicious for duloxetine by color and accessibility. Because there was the possibility of ingesting other medication(s) in addition to the one found in her mouth, it was medically necessary and appropriate to monitor her in the hospital. She was drowsy and a bit ataxic, with resolution of these symptoms within 48 hours. Because this was potentially not a single medication ingestion and there was possibility of further toxicity and/or evolving neurologic symptoms, acute inpatient admission was medically necessary. Management at a lower level of care would not have been safe or appropriate.