Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar Disorder, Obsessive Compulsive Disorder, Attention Deficit Hyperactivity Disorder.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld. 

This male adolescent patient has a medical history of attention deficit hyperactive disorder (ADHD), obsessive compulsive disorder (OCD), and bipolar disorder and presented to the Emergency Department (ED) via ambulance after ingesting clonidine tablets at home. The patient's mother reported that the patient did not want to do his homework and play video games, became angry and agitated and took about 10 to 15 pills of clonidine in front of her.  

The patient was currently prescribed Adderall, Abilify and clonidine. The patient's mother reported that the patient had one episode of vomiting after taking the pills, and he gradually became drowsy, but was able to enter the ED walking by himself. His last psychiatric admission was for suicidal ideation. The patient's physical examination noted tachycardia and bradycardia with hypotension. In the ED, there was no altered mental status (AMS), and there was slight lethargy and heart rate (HR) 52-57 and blood pressure (BP) 113/73, and oxygen saturation 99% on room air. The patient received intravenous (IV) fluids and naloxone IV push (IVP) in the ED. He was admitted to the Pediatric Intensive Care Unit (PICU) for further evaluation and management of intentional clonidine overdose. The patient was placed on one-on-one observation with continuous cardiopulmonary monitoring. He was closely monitored in the PICU overnight and continued on intravenous (IV) fluids and naloxone IVP x 2.  The patient had no electrocardiogram (EKG) interval prolongation such as QRS or QT prolongation. He was transferred to the floor after his vital signs and clinical condition improved.  Psychiatry was consulted for suicidal attempt by overdosing on prescribe medication.  The patient was medically cleared for transfer to a psychiatric hospital.

Poisoning with clonidine classically presents with somnolence, respiratory depression, hypotension, bradycardia, and miosis. Alteration in the level of consciousness usually presents within the first one and a half hours, preceding any cardiovascular effects which usually present within 4 hours. The majority of clonidine overdoses in adults and children have not been shown to cause significant symptoms requiring major intervention. Death or the need for invasive intervention such as intubation or use of vasopressors are rare and are reported only in extreme cases, for example with very young age or extremely large dose/patch ingestion.

In this case, the dose patient ingested was 1 milligram (mg) and this dose can be a pharmacologic dose in some patients. Sometimes the psychiatrists use 2.4 mg to attain the therapeutic effect. This patient did not have sustained bradycardia or any need for Narcan infusion. The role of Narcan in clonidine ingestion is controversial. There was no need for oxygen or any need for positive pressure ventilation for this patient. There was also no need for pressor support and no need for central lines or need for multiple boluses. This patient's hospital course was uneventful and there were no major, abnormal lab findings.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient could have been managed in an observational status.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.