Appeal type: Medical necessity
Decision: Upheld

The patient is a young female who was brought in by ambulance with no significant past medical history who presented with shaking. Her mother reports she was breast-feeding the patient and she had one episode of emesis and then started having seizure like activity for about three minutes. She began to have twitching of her body on both sides with increased tone and arching of her back. Her lips turned blue and resolved on its own. EMS was called and they arrived within five minutes. When EMS arrived, she had stopped seizing but was feeling weak and lethargic. Within minutes she was active and responding well. There was no frothing and no injuries from seizure. The patient's mother describes another such episode about three weeks prior with throwing up after feeding and a staring look for a few seconds. The mother fed the patient and put her in her walker when she spat and had this brief episode. That time there was no twitching of her body. The mother also reported diarrhea, 2 to 4 episodes, for the past three days prior to presentation. There was no blood and no mucus.

The ER examination revealed pulse 154, temperature 99F, respirations 40, and oxygen saturation 100% on room air. She was described as active and in no distress, neurologically she was alert with normal strength and normal muscle tone. Laboratory studies were done as well as a chest x-ray. The chest x-ray was normal, and electrolytes revealed mildly low sodium. A Neurologist was consulted from the emergency room, who recommended an EEG. The plan was to place patient in observation for further work up of possible new onset seizure.

The admission exam describes the child as cooperative and in no distress, neurologically normal without focal findings. The admitting diagnosis was seizures, gastroesophageal reflux disease (GERD) with Sandifer syndrome. The plan was to admit for an electroencephalogram (EEG) the following day, neurology consult, Ativan as needed for seizures, and neuro checks Q4 hours. A progress note the following day reports the patient remained seizure free overnight. She was afebrile. She had four episodes of diarrhea of the day prior in the afternoon but no further episodes after that. She was eating, drinking, and passing urine well. The patient had an EEG done but she was not sleeping and there were too many movement artifacts. The plan was for the EEG to be repeated under sedation as an outpatient along with an MRI of the brain under sedation as an outpatient. 

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. This patient presented with an episode of shaking, stiffening and blue lips that self-resolved. There was concern for possible seizure. Upon presentation she had no focal neurological findings, altered mental status and furthermore she had unremarkable laboratory values. She was not toxic appearing and she did not have any vomiting. Her vital signs were stable. The plan at admission was for Pediatric Neurology consultation and EEG. While admitted she did not require any complex or highly technical skilled care. She was observed and had no recurrence of symptoms.