Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of global developmental delay, a renal cyst, and autism spectrum disorder. He has been diagnosed with 17q12 deletion syndrome. A report by the pediatric neurologist notes that his family described his behavior as being very aggressive and difficult to control. Admission and progress notes describe that hyperactivity precluded a full neurological examination.
The patient had two witnessed tonic seizures with gaze deviation while at school. The first seizure lasted 3-4 minutes, followed around 1 minute later by a further seizure lasting 1-2 minutes. Paramedics were called, and he was transported to the emergency room. His examination was reported as being non-focal. The white blood cell count was elevated at 15.6. The glucose was elevated at 120. He had not had a history of a fever or constitutional symptoms.
He was admitted for seizure management and video electroencephalogram (EEG) telemetry. The video EEG showed mild generalized slowing, but no epileptiform activity. He was started on Depakote, with diazepam as a rescue medication for breakthrough seizures. He had no further seizures during his hospital stay.
At issue is whether inpatient admission was medically necessary.

The requested health service/treatment of inpatient stay was medically necessary for this patient. 

He had 2 witnessed seizures in 1 hour. He was at increased risk for further seizures and status epilepticus. He had focality to the seizures, with gaze deviation noted. He has a history of aggressive and difficult to control behavior. It was medically necessary to monitor his response to anticonvulsant medication to confirm that it did not exacerbate his severe behavioral issues. Video EEG telemetry excluded ongoing subclinical seizure activity, but was abnormal, with generalized slowing.
Sogawa et al [1] performed a retrospective chart review of children who presented to Schneider Children's Hospital Emergency Department in New York following a single unprovoked seizure. They described that "twenty percent of admitted patients had one or more seizures within 24 hours. Multiple seizures before the emergency department arrival was a significant risk factor for acute recurrence (33%, probability [P] less than [<] 0.05). Based on our findings that 20% of admitted children had one or more seizures within 24 hours, we think it is justified to admit and observe the children with seizures who are not on antiepileptic medications if the follow-up cannot be ensured."
Sartori et al [2] performed a retrospective review of 108 children with a first time seizure presenting to a hospital emergency room. Factors significantly associated with a diagnosis of epilepsy were the 'unprovoked' nature of the first seizure, age older than 6 years, pre-existing neurological conditions/problems, and focal onset of first seizure. This patient's witnessed seizures had four risk factors for epilepsy.
Lukmanji et al [3] reviewed seventy-four studies reporting on 283,549 patients with autism spectrum disorder. The median overall period prevalence of epilepsy in people with autism was 12.1%. There is a significantly increased risk of epilepsy in individuals with autism spectrum disorder. With regard to the need for observation following the introduction of an anticonvulsant medication in a child with autism and severe behavioral issues, Watkins et al [4] note that: "Autism and epilepsy should be approached under a neurodevelopmental model with cautious introduction and titration of anti-seizure medication."
The 17q12 deletion syndrome is associated with autism, epilepsy, and with a range of neuropsychiatric disorders as described by Mitchel et al [5]: "The 17q12 recurrent deletion syndrome is characterized by variable combinations of the three following findings: structural or functional abnormalities of the kidney and urinary tract, maturity-onset diabetes of the young type 5 (MODY5), and neurodevelopmental or neuropsychiatric disorders (e.g., developmental delay, intellectual disability, autism spectrum disorder, schizophrenia, anxiety, and bipolar disorder)."