Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This case involves a child who presented to the hospital.  The parents reported that the patient was riding their bike and fell off, hitting the back of their head.  It was stated that the patient began to seize.  The father reported unresponsiveness, cyanosis, and agitation.  The family described that the patient had rolling of the eyes, generalized tonic-clonic movement, and frothy secretions coming from the mouth.  At presentation to the emergency department, the patient was cyanotic and agitated.  There was no history of previous similar attacks.  The mother reported that the patient had an upper respiratory infection 1 week prior.  The patient was treated with antihistamines and antibiotics.  The patient had been admitted to the hospital 3 months ago for gastroenteritis for 1 day and then was sent home.  The review of systems was positive for cyanosis, seizures, and syncope.  The patient's oxygen saturation was 99% and the heart rate was in the 150s.  Emergency department triage vitals reported pulse of 122, respirations of 22, temperature of 98.8 Fahrenheit, and oxygen saturation of 100% on room air.  History and physical reported respirations of 40 with a pulse of 144.  The patient was crying at the time.  There was Babinski plantar flexor on the left and withdrawal on the right.  The impression was first episode of unprovoked seizure.  There was a plan for admission.  The patient's complete blood count with platelet and differential was within normal limits.  The basic metabolic panel was within normal limits.  Venous blood gas was within normal limits.  COVID-19 testing was negative.  Computed tomography of the head was limited by motion.  Low attenuation changes were noted in the left temporal lobe which could possibly be due to artifacts.  However, edema or encephalomalacia were not definitively excluded.  Intracranial hemorrhage or obstructive hydrocephalus were not seen.  The patient was treated with midazolam.  The patient was to have neuro checks every 4 hours, Ativan as needed, magnetic resonance imaging of the brain, electroencephalogram, and seizure precautions.  Electroencephalogram showed generalized 1 hertz (hz) spike and wave discharges, predominantly frontal area.  Magnetic resonance imaging (MRI) of the brain was normal.  The patient was assessed with generalized seizure disorder.  The patient started on Keppra.  The patient was deemed stable for discharge.

Per the cited references, admission to the hospital for pediatric seizure is indicated when there is hemodynamic instability, when there is a brain disorder that requires monitoring or intervention available only inpatient level of care, when there is altered mental status that is severe or persistent despite appropriate treatment, when there is new focal neurological deficit, or when there is metabolic disorder that persists despite observation care.  In this case, the patient presented to the hospital with new onset seizure.  It was stated that the patient had persistent altered mental status following seizure which required continuous monitoring.  However, while altered mental status was noted, the documentation did not support that this was considered severe or that it persisted despite appropriate treatment.  The documentation did not identify hemodynamic instability, or brain disorder that required monitoring or intervention available only inpatient level of care, new focal neurological deficit, or metabolic disorder that persisted despite observation care.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient stay is not substantiated.