Diagnosis: Foreign Body of Alimentary Tract.
Treatment: Inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is upheld.

This is a patient who presented to the Emergency Room (ER) after swallowing a penny. A chest x-ray was performed that confirmed that the penny was in the mid esophagus. He was admitted to the hospital for further evaluation. The patient underwent a esophagogastroduodenoscopy (EGD) with foreign body removal; a penny. He tolerated the procedure well and was discharged home


Per Joyamaha, D., & Conners, G. P. (2015), "Foreign body ingestion is common among children. A variety of foreign bodies are ingested, most of which are harmless and pass spontaneously through the gastrointestinal (GI) tract. There are a few particularly harmful and life threatening objects that should be identified and removed immediately to avoid serious complications."

The penny required removal and it was removed within 24 hours of presentation. This is sound medical care. He was placed nothing by mouth (NPO) and given intravenous (IV) fluids overnight but the penny did not fall into the stomach, so it needed removal and this was done appropriately. However, the patient did not need a formal inpatient admission. He could have received identical excellent treatment using an observational admission. The patient had no fever, had normal vital signs, had no surgical problem, had no infection. Overall he was clinically stable. The NASPGHAN guideline (2015) states that esophageal coins should be removed withing 24 hours, as done in this case. This procedure can be considered an outpatient procedure. The procedure is considered to be done using general anesthesia, so usually the procedure cannot be done immediately. In addition, often when the patient is placed NPO overnight, the coin falls into the stomach and no removal is necessary. Medical care was done correctly, but the patient did not meet criteria for a formal inpatient admission. This could have been done using observational status. Therefore, the inpatient hospital admission is not considered medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.