Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Seizure.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a school aged male child that was taken to the ED (emergency department) after manifesting abnormal behavior at school. He did not respond to his name in class, and when he was taken to the office, he was walking abnormally. He was able to talk to the school nurse, but his legs were making jerking movements and he seemed distant. The nurse contacted the parents, and the father went to the school to pick him up and take him to the ED (emergency department). The father also noted an abnormal gait, walking with rigid legs. The patient was back to baseline when they arrived at the ED (emergency department). He had had a similar episode in the past associated with shaking. He had also been evaluated in the past for chronic headaches occurring in the morning associated with nausea. The patient's vital signs included temperature 98.3, heart rate 78. Examination was significant for no acute distress, evidence of bitten tongue, moist mucous membranes, no meningismus, clear lungs, regular heart rate and rhythm, benign abdomen, no papilledema, and non-focal neurology exam. He had no spells in the ED (emergency department). Attempts were made to contact the physicians that had evaluated him in the past, with recommendations to admit for work-up of new-onset absence seizures. The patient's mother had history of seizure as a young child but was not treated with anticonvulsant medications. Laboratory evaluation included viral respiratory panel returned negative. Admission orders included neurochecks every four hours, Neurology consultation (with recommendation for video EEG [electroencephalogram]), Cardiology consultation for echocardiogram, screening blood work, and lorazepam as needed for prolonged seizure activity. Laboratory evaluation was significant for WBC (white blood cell) count 12.4K (thousand), alkaline phosphatase 564, and concentrated urine with pH 1.030. The video EEG (electroencephalogram) was unremarkable both awake and asleep. Both electrocardiogram and echocardiogram were unremarkable. The patient remained on video EEG (electroencephalogram) for 24 hours with no abnormalities. He had no spells during his hospital stay. 

The Inpatient Hospital Admission was not medically necessary.

The differential diagnosis of first-time afebrile seizure activity is quite broad, and includes head trauma, abuse, toxic ingestion (intentional or accidental), infection, 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 electroencephalogram (EEG) and MRI (magnetic resonance imaging), 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. Risk for seizure recurrence is greatest within the first six months. 
This child presented to the ED (emergency department) following a spell of unresponsiveness followed by abnormal gait and decreased interaction. He had experienced a similar spell a year prior that wasn't brought to medical attention. He also suffered from chronic morning headaches associated with nausea that were brought to medical attention, with subsequent unremarkable evaluation. There was concern for absence or partial seizures, so he was monitored for 24 hours with 
video EEG (electroencephalogram), ultimately unremarkable. Screening labs and cardiology evaluation were also unremarkable. He was overall hemodynamically stable with no evidence of status epilepticus or significant underlying illness. He did not require acute inpatient admission and could have been safely managed at a lower level of care.