Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This case involves a male with a history of autism and verbal delay who was seen in the emergency department as a transfer from a separate facility due to seizures.  At the time of his assessment in the emergency room, a head computed tomography (CT) showed no definite evidence of an acute lobar infarction, no acute intracranial hemorrhage, no mass-effect or midline shift.  There was no evidence of hydrocephalus, the calvarium was intact, with moderate to marked left sphenoid sinus disease. He had minimal thickened secretions suggested in the right sphenoid sinus with mild to moderate bilateral ethmoid sinus disease and mild bilateral maxillary sinus disease. Laboratory values noted that CO2 (carbon dioxide) was 19, calcium was 6.1 and the ALT (alanine transaminase) was 441. The patient was started on calcium gluconate intravenously. His EKG (electrocardiogram) was normal, and he showed improvement, had awaken, and was back to baseline and interacting with his mother. The indication was of hypocalcemia. Records indicated that on the date of the patient's seizure, he had awakened for breakfast for Ramadan, ate a meal, and was playing on the phone next to his mother when he was noted to have shaking movements of the right upper extremity that generalized into the whole body. He was postictal on arrival to the emergency department with eye roving movements and no gaze preference. The patient was confused with return to baseline over the subsequent few minutes. The patient had a low-grade fever over the past few days along with a runny nose and mild cough. He was otherwise acting himself with no change in oral intake, and no vomiting or diarrhea. 

According to the Milliman Care Guidelines regarding pediatric seizures, admission for inpatient care is based upon one or more of the following criteria to include that the patient has hemodynamic instability, febrile seizure and the child is older than 5 years, has focal seizure activity, has a prolonged seizure 15 minutes or more, has more than one seizure within 24 hours, and when there is suspicion for meningitis.  Additionally, if the patient is status epilepticus, has a brain disorder that requires monitoring or intervention available only at an inpatient level of care, if the etiology, such as drug toxicity, withdrawal, or nonadherence requires monitoring or intervention available only at an inpatient level of care or that persists despite observation care, when there are cardiac arrhythmias of immediate concern, altered mental status that is severe or persistent, when there is new focal neurologic deficit, metabolic disorder, recurrent seizures, outpatient epileptic regimen cannot be established, when
there is need for monitoring cerebral bleeding, hydrocephalus, or vasospasm monitoring, or increased intracranial pressure or cerebral edema. Upon a review of this information, it was determined that the inpatient care was reasonable given that the patient had a prior history of seizure with no further work-up initially, and because of the abnormalities noted during his assessment after initial assessment the inpatient care was necessary to provide the patient appropriate care should he have recurrent seizure(s) that cannot be addressed on a lower level of care.  In taking the patient's age into consideration, and prior history, the recommended services were supported. As such, the denial of coverage for the inpatient admission was medically necessary.  

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.