Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female that was born prematurely secondary to placenta previa that was taken to the emergency department (ED) via Emergency Medical Services (EMS) with seizure activity. She had a week-long history of cold symptoms including cough and congestion. She had three episodes of full body shaking that self-resolved. She previously had similar episodes. She was hospitalized with those episodes, evaluated by neurology, with a negative Video Electroencephalogram (VEEG), and prescribed rescue with rectal Valium. On the day of presentation, she had a fever to 103 that was treated with Tylenol. About ten minutes later, she had a spell of rigidity with tonic-clonic movements and blank stare, followed by ten minutes of confusion. There was no trauma. The spell began while she was being held and she was lowered carefully to the ground and placed on her side. Her appetite was poor over the course of this illness with decreased production of wet diapers. She was followed by neurology and a brain magnetic resonance imaging (MRI) had been scheduled.
Her vital signs included temperature 100.4, heart rate 132, and her respiratory rate was 24. Her bedside glucose was 83. Her oxygen saturation on room air was 98 percent (%). The examination was significant for no distress, awake and consolable by parent, clear rhinorrhea, moist mucous membranes, clear lungs, benign abdomen, and non-focal neurologic exam. The laboratory evaluation was significant for an elevated C-reactive protein (CRP) 1.3, aspartate aminotransferase (AST) 47, alkaline phosphatase 223, normal white blood cell count (WBC) count 8.0 with 28% (percent) neutrophils and 28% (percent) band neutrophils, positive adenovirus, and positive parainfluenza type 3. She was admitted for further management.
The admission orders included diet as tolerated, seizure precautions, neuro checks every six hours, Ativan as needed for prolonged seizure, antipyretics, neurology consultation, VEEG (Video Electroencephalogram), consideration for MRI (magnetic resonance imaging), and intravenous (IV) fluids if poor oral intake. The VEEG (Video Electroencephalogram) remained normal for the two days that she was monitored. She was cleared for discharge by both the neurologist and the epileptologist after ruling out epilepsy.
 
Febrile seizures occur in up to 5% (percent) of children ages 6 months to 5 years. The peak occurrence is between 18 months and 3 years, with markedly decreased incidence in children after 4 years of age, and rarely occurring after 7 years of age. Febrile seizures are more common in Asian and Indian populations. Males have a higher incidence than females, there is association with certain vaccines (measles, mumps, rubella, and varicella (MMRV)), and there are two seasonal peaks (November-January, June-August) associated with prevalence of common viral illnesses (respiratory and gastrointestinal, respectively). Febrile seizures are characterized as simple or complex. Simple seizures are generalized, lasting less than 15 minutes, with only one occurrence in 24 hours and no post-ictal period. Complex seizures deviate from one or more of those features, lasting longer than 15 minutes, having more than one seizure in 24 hours, with post-ictal period, and/or presenting as focal rather than generalized. There is a family tendency, with some genetic associations. Progression to a diagnosis of epilepsy is more likely to occur in association with neurodevelopmental abnormalities, complex febrile seizures, family history of epilepsy, age older than three years at the time of the first febrile seizure, and longer duration of fever. Initial evaluation of a patient with febrile seizure includes history, examination, and diagnostic testing to identify the source of fever. Lumbar puncture may be indicated in specific populations of patients.