Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a female child with no prior medical history who was seen in the Emergency Room after a shaking episode.  It was a witnessed event by friends who spent the night at the patient's home for a slumber party.  The patient's mother also witnessed the shaking episode.  The mother stated that the patient was on the floor and shaking for about 30-45 seconds and had associated urinary incontinence and upper eye gazing.  The mother reported no vomiting or bowel incontinence and no head trauma.  The mother reported that the patient was out of it for 5 to 10 minutes afterwards.  Of note, the patient went with her friends to an escape room the night before and had stayed up until 2 AM.  The patient was evaluated by a physician in the Emergency Room and was observed to be alert and oriented x3. She had no focal deficits. Her musculoskeletal system was grossly intact with no deficits noted, no meningeal signs, and a normal gait and coordination.  The physician noted that this appeared to be a first-time seizure.  The patient was subsequently transferred to a different hospital where they had the necessities available to treat the pediatric patient.  

In the interim, prior to transfer, the patient had a CT of the brain with that was an essentially unremarkable unenhanced CT scan of the brain.  Given the patient's clinical history, Neurology consultation and follow-up of the brain with an MRI, further evaluation and characterization was advised.  The patient was transported by ground ambulance to the Pediatric Emergency Room of the admitting hospital.  Vital signs revealed a blood pressure of 116/70, a heart rate of 78, a respiratory rate of 20, an oxygen saturation of 90% and a temperature of 98.6.  The neurological examination was grossly normal. The patient had no focal findings on the rest of her exam. The patient was giving a dose of Tylenol for headache and transferred to the floor for VEEG monitoring and further management.  The VEEG findings were consistent with epileptic disorder likely juvenile myoclonic epilepsy.  The patient was started on oral Keppra 500 mg every 12 hours which she was to be continued on when discharged.  There were no further seizures witnessed while the patient was hospitalized.

MCG states that for pediatric electroencephalogram [EEG] monitoring, the goal length of stay in the hospital is ambulatory and up to two days, dependent upon clinical status including the possibility of an anticonvulsant medication being prescribed.  MCG also states that inpatient admission for pediatric seizure may be appropriate for other condition, treatment, or monitoring requiring inpatient admission.  

In the clinical records submitted for review, there was documentation that the pediatric patient had a witnessed seizure at home. It was the first one.  The Neurologist was consulted and recommended a VEEG study and a diagnosis of epileptic disorder, juvenile myoclonic epilepsy was determined after the study.  An oral antiepileptic drug was started, and the patient was discharged from the hospital within one day.  Therefore, the inpatient admission was medically necessary and is reversed.  

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.