Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially presented to the emergency department with concerns for a seizure. Her pertinent history included seizure disorder, cerebral palsy, home oxygen of 4 liters (L) via nasal cannula (NC), coronary artery disease, asthma, pulmonary atresia and ventricular septal defect. Her initial vital signs revealed a temperature of 97.8 degrees Fahrenheit, heart rate (HR) 116, respiratory rate (RR) 24 and her peripheral capillary oxygen saturation (SpO2) was 80 percent (%). The initial examination documented the patient as alert with no focal deficits. The initial laboratory testing revealed a white blood cell count (WBC) of 7.7, hemoglobin 20.7, blood urea nitrogen (BUN) 23, creatinine 0.7, glucose 105, carbon dioxide (CO2) 18 and her lactate was 1.4.
The urinalysis showed pyuria, bacteriuria, and high amount of squamous epithelial cells. The electrocardiogram (EKG) was unremarkable with a heart rate of 88 beats per minute (bpm). The chest x-ray (CXR) was unremarkable. Keppra, a 1-liter fluid bolus, and Ceftriaxone were administered. The admitting physician had an impression of breakthrough seizure in a previously diagnosed seizure disorder, asymptomatic bacteriuria, and stable asthma. The patient was documented as awake and alert with stable hemodynamics and had an adequate SpO2 (oxygen saturation) on 3L (liters) NC (nasal cannula). The computed tomography (CT) of the head was unremarkable.
The treatment plan included continued Keppra, discontinuation of antibiotics, and a neurology consultation. Neurology was consulted who had a similar impression of a breakthrough seizure. Recommendations included continuation of home dose of Keppra and to obtain a magnetic resonance imaging (MRI) of the brain. There was no recurrence of seizure. Pulmonary was consulted and had an impression of chronic hypoxemia in this patient with history of pulmonary atresia/ventricular septal defect. Recommendations were to continue home oxygen therapy. The patient was discharged with plans for an outpatient electroencephalogram (EEG).

The American Academy of Family Physicians (AAFP) published guidelines regarding the evaluation and management of seizure, mainly first known episode. They note that the patient history and physical examination should focus on events directly preceding the seizure, the number of seizures in the past 24 hours, the length and description of the seizure, focal aspects (e.g., unilateral movements, eye deviation, head turning to one side), length of the postictal period, and the neurologic examination. This allows proper categorization as well as etiology identification and recurrence risk. Thereafter, in agreement with the American College of Emergency Physicians (ACEP), a CT (computed tomography) of the head with and without contrast should be performed to look for structural lesions. Both the AAFP (American Academy of Family Physicians) as well as the ACEP (American College of Emergency Physicians) note that stable patients who have returned to baseline neurologic status in the emergency department may be discharged and scheduled for outpatient neurology if follow-up can be ensured. Additionally, laboratory tests can be performed but should be tailored to the individual patient and driven primarily by findings from the history and examination (e.g., glucose level in a diabetic, liver function tests/ammonia in a cirrhotic).[1]
The patient had a history of seizure disorder and chronic oxygen dependence who presented with concerns for a breakthrough seizure. Initial laboratory testing, electrocardiography, and CT (computed tomography) of the head imaging was relatively unremarkable. The emergency department physician documented the patient as awake and alert without focal neurologic deficits. No other issues or complications were documented.

The health plan's determination of medical necessity is upheld in whole.