Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
Patient is a young child with events concerning for seizures. The patient presented with seizure like activity and had negative laboratory and electrocardiogram (EKG). Patient was recommended for discharge with outpatient follow up; however, after a second seizure episode the patient was admitted for electroencephalogram (EEG). Patient was given Ativan as needed (PRN) for seizures. During admission the patient was on her home medications including Budesonide nebulizer every 2 hours (q2h), Montelukast daily, and Albuterol 2 puffs every 4 hours PRN (as needed). She was placed on a regular diet. The continuous video electroencephalography monitoring report shows a normal EEG (electroencephalogram) in the awake, drowsy, and asleep state. There were no areas of focal slowing, epileptiform discharges, or electrographic seizures. The patient remained neurologically stable throughout admission.

There is no medical literature, standard of care or submitted documentation to support admitting this patient to the hospital. The patient had an event concerning for a seizure; however, she was not medically unstable. During admission the patient was on her home medications, on a regular diet, and remained neurologically stable. Therefore, the inpatient admission was not medically necessary.

Webb, J., Long, B., & Koyfman, A., "A seizure is caused by abnormal neurologic electrical activity resulting in altered motor, sensory, and behavioral symptoms. Other conditions may present similarly, causing a challenge in diagnosis. These conditions include syncope, psychogenic nonepileptic seizures, stroke or transient ischemic attack, sleep disorders, movement disorders, and migraines. Diagnosis of seizures in the emergency department (ED) is often clinical. Differentiation between seizures and other conditions can be difficult. Laboratories and imaging provide little benefit in definitive diagnosis in the emergency setting. For patients that have an apparent seizure, resuscitation and management is precedent while identifying any provoking factors and treatment of those factors. For adults recovering from suspected seizure, the combination of a focused history, physical examination, and additional studies can provide assistance in diagnosis."

Kazl, C., & LaJoie, J., "Seizures are a common presentation in both emergency departments and general pediatric practices. Epilepsy affects more than 3.4 million people nationwide, of which approximately 500,000 are children, with greater than 200,000 first-time seizures each year. 1 Of the affected individuals, as many as 100,000 are estimated to experience status epilepticus (SE). Both general practitioners and neurologists alike must be able to define, recognize and treat seizure emergencies. This review article defines and describes SE (status epilepticus), discusses the emergency evaluation and management of SE (status epilepticus) that is both new-onset and breakthrough in people with epilepsy, reviews the current treatment recommendations for SE (status epilepticus) in both the home and hospital settings, and introduces special populations that may be at high risk for SE (status epilepticus) or other seizure emergencies."

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 the inpatient admission is not substantiated.