Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures	
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld. 

 
This case involves a child who was brought into the emergency room for possible seizures after the patient's mother reported occasional episodes of blank stares over the past 1-2 years. The patient had reportedly not returned to baseline and was admitted for further evaluation by neurology. The emergency department report stated that when the patient arrived, he was alert and answered questions appropriately, but appeared tired and did not hold attention well.  A Computed tomography (CT) of the head was negative for acute intracranial pathology. The impression was of a new onset seizure due to unknown etiology without a return to baseline mental status. The report stated that the school guidance counselor witnessed a seizure described as a generalized tonic-clonic seizure, which lasted for around 1 minute. There was no frothing of the mouth, no stool, and no urine incontinence. Afterwards, the patient was sleepy.  The patient's mother noted that for the last few days, the patient was having frequent episodes of blank stares. There was no family history of seizure, and the patient was not on any medication. Other than a dose of Benadryl the Saturday before, he had not utilized any medication since then. The patient remained on inpatient status until he was discharged.

According to the Milliman Care Guidelines, inpatient care may be indicated when the patient is hemodynamically unstable, has febrile seizures, is status epilepticus, has a brain disorder that requires monitoring or intervention available only at inpatient level of care, with etiology requiring monitoring for intervention available only at inpatient level of care or that persists despite observation care. Also, when there is altered mental status that is severe or persistent, when there is no focal neurologic deficit, when the patient has a metabolic disorder that persists despite observation care, when there are recurrent seizures during emergency department or observation care, when outpatient antiepileptic regimen cannot be established, when there is a need for cerebral bleeding, hydrocephalus, or vasospasm monitoring, or increased intracranial pressure or cerebral edema monitoring. The information provided for the review did not support that the patient had any further seizure episodes in the emergency department, and with the Milliman Care Guidelines indicating that observation care is recommended when the patient has had there for seizure when they have not been previously diagnosed with a seizure disorder, and specific etiology require short-term observation, treatment, or correction, when medication initiation or adjustment requires brief observation, or when there is altered mental status upon postictal presentation to the hospital. Given the provided information, the patient was a suitable candidate for observation care. He did not meet criteria for inpatient/acute level of care.  

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 inpatient admission is not substantiated.