Two Cases of Suspected Abuse/Neglect in Young Children

Submitted by Erik Madsen, MD, PhD
Physician Advisor, Cardinal Glennon Children’s Hospital 

Type of Denial: Medical Necessity Retrospective
Age: 21 months and 3 years
Genders: Male
Insurance: Case 1 - Medicaid | Case 2 - Commercial
Length of Stay: Case 1 - 24 hours | Case 2 - 4 days
Reason for being Hospitalized: Suspected abuse or neglect

Hospital Course:

Case 1: 21 mo M with accidental fentanyl ingestion at aunt’s house. Responded to naloxone by EMS; transferred from outside E.D. to children’s hospital with normal mental status, no need for supplemental oxygen or repeat naloxone doses. Seen by toxicology. Evaluated by social work and children’s services and discharged home with parents on the next day.

Case 2: 3yo M with a chromosomal abnormality with developmental delay, hypopituitarism, OSA, GERD admitted to the hospital from the complex care clinic due largely to mother admitting her own mental illness was preventing the child from getting appropriate care at home and possible neglect from the child’s father. The child had a few minor medical problems: hyperglycemia (glucose 160) and a diaper rash, but required no significant treatment. Hospitalized 4 days while mother sought psychiatric attention and he was discharged home with his mother. 

Appeal Strategy:

Both cases were denied for lack of medical necessity for inpatient status; observation was allowed. Both cases were sent to peer to peer. The denial in Case 1 was upheld for lack of medical necessity and short length of stay.

The denial in Case 2 was overturned. The same argument was made in both cases, namely that MCG criteria allows for inpatient status in the case of “suspected abuse or neglect”. One medical director was amenable to this argument; one was not. The denied case was < 24 hours admission length and so we did not pursue appeal.