Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foreign Body in Digestive Trace

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld

The patient has a benign past medical history who came to the Emergency Department for assessment and management of a witnessed swallowed button battery. The father noted that the child appeared anxious or in pain so he gave a spoon full of olive oil with improvement in minutes. He was asymptomatic at presentation. His vitals were notable for temperature 36.1 Celsius, heart rate 105, respiratory rate 22, blood pressure 121/73 and oxygen saturation of 98% (percent) on room air. His physical exam was unremarkable. His admitting weight was 24 kilograms and his height was 103 centimeters. No laboratories were performed. Imaging included a chest/abdominal x-ray that showed a 1.2 centimeters (cm) button battery within the stomach. A phone consultation with pediatric gastroenterology recommended admission to the hospital, serial abdominal exams and repeat films the following day. Patient was given a single oral dose of Carafate and a regular diet. He remained afebrile with stable vitals and no symptoms throughout the admission. A repeat abdominal x-ray showed passage of the battery to the lower central pelvis - possibly rectum. He was discharged home (< 24 hours after presentation) for outpatient follow-up.
 
This infant child swallowed a 1.2 cm button battery with no symptoms, normal vitals and normal physical exam on presentation. In addition, an abdominal exam showed that the battery had passed into the stomach in less than 2 hours.
 
According to the National Capital Poison Center Button Battery Ingestion Triage and Treatment Guidelines a patient with these characteristics should be managed as follows:

"Allow batteries to pass spontaneously if they have passed beyond the esophagus (stomach and beyond) and no clinical indication of significant gastrointestinal injury is evident.  Manage the patient at home on a regular diet. Encourage activity. Avoid unnecessary endoscopic or surgical removal in asymptomatic patients. Promptly re-evaluate all patients who develop signs or symptoms possibly related to the battery. Endoscopic removal of batteries still in the stomach should be pursued for even minor symptoms. For batteries beyond the reach of the endoscope, surgical battery removal may be required in the unusual patients with evidence of occult or visible bleeding, abdominal pain, profoundly decreased appetite, vomiting, signs of an acute abdomen, and/or fever, unless these clinical manifestations are clearly unrelated to the battery. Confirm battery passage by inspecting stools. Consider repeat radiographs to confirm passage if passage not observed in 10-14 days. Confirming passage may avoid urgent diagnostic intervention for minor symptoms developing later."

This asymptomatic patient with a button battery < 2cm, that had already passed into the stomach could have been managed in the outpatient setting with an x-ray in 10-14 days or sooner if symptoms develop. Given these factors the acute care admission was not medically necessary nor was it in the best interest of the patient as supported by the literature. The health plan acted reasonably. This decision was rendered based on review of the hospital record and the references cited above.

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