Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The inpatient admission was not medically necessary.

The patient is a female child that was taken to the emergency department (ED) via Emergency Medical Services (EMS) because of two episodes of unresponsiveness followed by slow arousal concerning for seizures with post-ictal period. She had been having similar episodes for a couple weeks with staring and apparent sudden loss of consciousness followed by spontaneous resolution. She had been seen by Neurology the previous day. Because of increased episodes, she was taken to the ED for further management. There were no shaking movements or urinary incontinence. They were referred to the ED by a different physician for work-up including video electroencephalography (EEG). 

Vital signs included temperature 98.2, heart rate 101, and respiratory rate 20. Examination was significant for bitten tongue, moist mucous membranes, and non-focal neurologic exam. Laboratory evaluation including complete blood count (CBC), complete metabolic panel, urine toxicology, and urinalysis was all negative. The patient remained neurologically stable in the ED, with increasing level of alertness. The case was discussed with the outpatient pediatrician that referred her for inpatient admission. Admission orders included clear liquid diet, serial neurologic exams, intravenous (IV) fluids, and Neurology consultation. In consultation with Neurology, magnetic resonance image (MRI), and video EEG were ordered. Electrocardiogram was also obtained and was normal. The video EEG was resulted as preliminary, and was reported as a normal study. Upon completion, however, the study was reported as abnormal with intermittent posteriorly dominant diffuse theta activity seen sporadically during drowsiness and wakefulness with rare bursts of isolated diffuse spikes with after-going multiple waves lasting up to two to four seconds seen during drowsiness and sleep indicative of new onset evolving generalized epilepsy with history suggestive of absence seizures. MRI was obtained as well, and revealed no significant intracranial abnormality. The patient was started on Keppra and discharged the next day, to follow-up with Neurology for a routine EEG. 
... 
Characterization of the type of seizure is also important, differentiating between febrile and afebrile, focal and generalized. "After the initial acute investigation, which often includes metabolic and CT scanning, depending on the clinical presentation in emergency room, in a child with a first nonfebrile seizure, it is recommended to obtain an EEG to help predict the risk of seizure recurrence. Subsequent imaging studies with MRI should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neurologic or psychiatric examination, a seizure of focal onset with or without secondary generalization, an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children younger than 1 year of age. Other laboratory tests or lumbar punctures may be pursued depending on the specific clinical settings." (1) Medication may or may not be necessary depending on the clinical presentation. Risk for seizure recurrence is greatest within the first six months. (2)

This child presented to the ED with staring spells followed by altered mental status that was increasing over the course of a couple weeks. She had been seen by Neurology outpatient, and with the evolution of the spells, recommended video EEG and MRI. While it was important to do a full evaluation on this child, she was overall hemodynamically stable without any evidence of dehydration or sepsis or other concerning clinical issue. She did not require acute inpatient admission and could have been safely managed at a lower level of care.