Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient emergency admission
The health plan denied Inpatient emergency admission.
The determination is Upheld.

The patient is a male child born at 37 weeks' gestation that was carried into the emergency department (ED) by his mother after having a shaking episode that lasted about two minutes while sitting in his highchair. He vomited after the spell and seemed out of focus then returned to baseline. He was at baseline upon arrival to the ED (emergency department). His vital signs included a temperature of 37 degrees Celsius, a heart rate of 170 beats per minute (bpm), and a respiratory rate of 34/minute, with 94 percent (%) saturation in room air. Examination was significant for no acute distress, moist oral mucosa, no oral lesions, clear lungs, benign abdomen, non-focal neurologic exam, and scaly erythematous rash to the buttock region consistent with diaper dermatitis. His fingerstick glucose was 100. The laboratory evaluation was significant for a carbon dioxide (CO2) of 16.2, a glucose of 72, a white blood cell (WBC) count of 13.7, an aspartate aminotransferase (AST) of 59, an alanine aminotransferase (ALT) of 32, an alkaline phosphatase of 230, and a negative rapid viral screen. The chest x-ray was negative. An electrocardiogram (EKG) was remarkable only for sinus tachycardia.
Pediatrics was consulted with recommendations for short stay admission for mild dehydration and electroencephalogram (EEG) evaluation for suspected seizure. Further history revealed a recent bout of diarrhea attributed to milk protein allergy and a two-vessel umbilical cord. Admission orders included EEG (electroencephalogram), maintenance intravenous (IV) fluids, repeat lab studies, and gastrointestinal (GI) polymerase chain reaction (PCR) and stool guaiac testing. Stool testing was guaiac negative, and positive for sapovirus. The EEG (electroencephalogram) was interpreted as normal. A repeat metabolic panel revealed improved CO2 (carbon dioxide) greater than 18. He did well and was cleared for discharge to follow-up with his pediatrician in two days. At issue is the medical necessity of the inpatient emergency admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient emergency admission was not medically necessary for this patient.
The differential diagnosis of first-time afebrile seizure activity is quite broad, and includes head trauma, abuse, toxic ingestion (intentional or accidental), infection (certain GI (gastrointestinal) infections like Rotavirus and more recently Norovirus), elevated intracranial pressure, and anatomic abnormalities. Initial evaluation must include a complete history and comprehensive physical examination to identify possible life-threatening causes of seizures. Characterization of the type of seizure is also important, differentiating between febrile and afebrile, focal and generalized. The initial work-up generally includes screening labs, toxicology, and brain imaging. In the case of first-time afebrile seizure, recommendations generally include EEG (electroencephalogram) and magnetic resonance imaging (MRI), particularly if there are other features like headaches, significant cognitive or motor impairment of unclear etiology, focal seizure regardless of generalizing, or age younger than one year. Medication may or may not be necessary depending on the clinical presentation. Risk for seizure recurrence is greatest within the first six months.
This young male child presented with diarrhea, an episode of vomiting, and a shaking episode concerning for seizure. Examination and work-up in the ED (emergency department) revealed metabolic acidosis indicative of mild dehydration. Additional work-up revealed sapovirus infection. The EEG (electroencephalogram), EKG (electrocardiogram), and chest x-ray were all negative. While it was reasonable to monitor in the hospital setting while evaluating for seizure, he was overall hemodynamically stable, with no significant dehydration and no further shaking spells.