Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ingestion of pills
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is a toddler male child. He was taken to the ED (emergency department) after suspected ingestion of some of his grandfather's medications. The medications that were in the pill box included clopidogrel, Entresto, metformin, glimepiride, Eliquis, atorvastatin, metoprolol, and multivitamin. The child was at his baseline level of activity with no lethargy, no vomiting, and no distress. Pills did not include acetaminophen or aspirin. Parents called Poison Control and were instructed to take him to the ED (emergency department) for evaluation. The patient's vital signs included temperature 36.2 (degrees Celsius), heart rate 122, respiratory rate 28, blood pressure 99/67. Examination was significant for no acute distress, playful, moist oral mucosa, regular heart rate and rhythm, clear lungs, benign abdomen, and non-focal neurologic exam. Bedside blood sugar was 105 on two occasions, 90 minutes apart. The family had brought in the pill box with remnants of glimepiride and Eliquis. The other pills appeared to be intact with some disintegrating coatings noted. Poison Control was contacted with recommendations for checking blood sugar every one hour for four hours then every two hours until stabilized, with unrestricted access to food and water, with D25 (25% [percent] Dextrose) if hypoglycemic (glucose less than 60). They also recommended monitoring for hyponatremia. The initial plan was to monitor the child in the ED (emergency department), with eventual admission for ongoing blood sugar monitoring. Laboratory evaluation was unremarkable. Admission orders included continued blood sugar monitoring per Poison Control, repeat metabolic panel in the morning, cardiac monitor, and pediatric diet. Overnight, blood sugars remained stable (glucose 84-178), the patient was eating well, and he had no changes in activity. Repeat metabolic panel was unremarkable (sodium 137-139). He was deemed stable for discharge after 24 hours of monitoring, to follow-up with his pediatrician in a week.

The inpatient admission was not medically necessary.

This young child was with his grandfather under his grandfather's care when he found the pill organizer. There were a number of medications in the organizer, including two oral hypoglycemics, cholesterol medication, two blood thinners, and a blood pressure medication. The child seemed to chew on one of the oral hypoglycemics and one of the blood thinners. His screening labs were unremarkable, with normal platelets, coagulation studies, and bedside/serum glucose. He did not ingest a significant amount of any of the medications, but with the potential for hypoglycemia, altered coagulation, and hyponatremia, he was monitored in the hospital overnight with serial bedside glucose monitoring and repeat metabolic labs. While this was a reasonable and medically appropriate course of action, the child remained hemodynamically stable with no evidence of hypoglycemia, no bleeding or bruising, no metabolic derangements. He did not require acute inpatient admission, and he could have been safely managed at lower level of care.