Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Loss of consciousness and seizure. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is a young adult male who presented to the emergency department after presenting with loss of consciousness and seizure like activity. According to the provided documentation, he complained of dizziness and then lost consciousness, and had witnessed shaking for approximately two minutes. On awakening, he was confused for about 15 minutes before returning to baseline. He apparently had a second episode and had a third episode in the emergency department. The history also indicates a similar episode 2 years prior. He complained of intermittent headaches for the previous week. He also complained of vomiting after eating for one month. A head computed tomography (CT) scan performed on presentation was negative. He was seen by neurology who recommended video encephalogram (VEEG) monitoring. Myocardial infarction was ruled out with troponins. He was placed on cardiac telemetry with no arrhythmia found though did have sinus tachycardia. He had a fever and workup revealed adenovirus. 

There is no specific medical necessity for acute inpatient hospitalization. This is patient presented with loss of consciousness and seizure or seizure like activity. Differential diagnoses: epileptic seizure versus convulsive syncope. The patient appropriately underwent a head computerized tomography (CT) scan while in the emergency department. Troponins were drawn to evaluate for acute cardiac event. Echocardiogram was also performed to evaluate for the structural abnormality of the heart. 

These can be completed in the emergency department or observation setting. There is no need for acute inpatient hospitalization. Once an acute intracranial abnormality, acute cardiac event and arrhythmia were ruled out, the patient could have been safely discharged with plans for further evaluation as an outpatient. There is no specific medical necessity for the immediate provision of video electroencephalogram (VEEG) monitoring. 

The patient showed no outward or laboratory signs of sepsis or any other infectious process that would support the need for an acute hospital stay. 

Per Xixis, K. L., Samanta, D., & Keenaghan, M. (2022), "Febrile seizures are seizures that are caused by a sudden spike in body temperature with fevers greater than 38C or 100.4F, with no other underlying seizure-provoking causes or diseases such as the central nervous system (CNS) infections, electrolyte abnormalities, drug withdrawal, trauma, genetic predisposition or known epilepsy. Febrile seizures categorize as either simple febrile seizures or complex febrile seizures. Differentiation between simple and complex febrile seizures is important as the approach and workup for each is different. There is no specific treatment for simple or complex febrile seizures other than appropriate treatment for underlying etiologies driving the ongoing febrile illness.  Antipyretics have not been shown to prevent a recurrence of febrile seizures.  In patients who have a frequent recurrence of febrile seizures such as seizures with a majority of febrile illnesses, studies have examined treatment with benzodiazepines as a bridging measure for a few days during subsequent febrile events. Febrile status epilepticus can occur in less than 10% of children during the first febrile seizure. Rectal diazepam is used to abort this disorder if it lasts more than 5 minutes. There are also recommendations for intranasal midazolam. Patients with febrile status epilepticus are at risk for future episodes of the same event." 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient is not substantiated.