Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a partially vaccinated little girl that presented to the ED in the afternoon via EMS after having a febrile seizure at home. 

Review of systems revealed sore throat, cough, thick mucus, and poor intake. She had fever to 103.7 earlier in the day. Seizure was described as generalized tonic-clonic lasting ten seconds with loss of bladder control, with a 30-45-minute post-ictal period. Vital signs included temperature 99.1, heart rate 130, respiratory rate 22, and blood pressure 96/54. Physical examination was significant for no distress, sleepy but arousable, clear ears, clear throat, clear lungs, benign abdomen, no rashes, and brisk capillary refill. She had no meningeal signs and no neck stiffness. 

Laboratory evaluation revealed leukocytosis (WBC [white blood count] 19.4K, 87% neutrophils), elevated lactate (5.9), hyponatremia (sodium 128), metabolic acidosis (CO2 [carbon dioxide] 18), negative urinalysis, negative influenza, elevated CRP (C-reactive protein) (3.32), elevated procalcitonin (27.18), and normal venous blood gas. She was evaluated two hours after presentation and was noted to be well-appearing with mild congestion and non-focal neurologic exam, sitting up and eating a sandwich. 

Laboratory studies had improved following fluid bolus (sodium 130, CO2 19, WBC 14.0K, lactate 2.5). Chest x-ray was unremarkable. The patient was diagnosed with febrile seizure complicated by prolonged post-ictal state and hyponatremic dehydration. Pediatric Neurology recommended admission for observation but no lumbar puncture in the absence of meningeal signs. Admission orders included ceftriaxone pending blood culture results per Infectious Disease recommendation. 

The patient did well throughout her hospital stay, with resolution of fevers, no further seizure activity, and normalization of labs. She was eventually given a diagnosis of clinical bacterial pneumonia (likely due to Pneumococcus given inadequately immunized state) and discharged home to complete a course of Augmentin.

Febrile seizures are not an uncommon event, occurring in two to five percent of children ages six months to five years. The peak occurrence is between 18 months and three years, with markedly decreased incidence in children after four years of age, and rarely occurring after seven years of age. Febrile seizures are more common in Asian and Indian populations. Males have a higher incidence than females, and there are two seasonal peaks (November-January, June-August) associated with prevalence of common viral illnesses (respiratory and gastrointestinal, respectively). Most febrile seizures are simple, meaning that they are generalized, lasting less than 15 minutes, occurring only once in a 24 hour period, with no significant postictal period. Complex febrile seizures exhibit one or more of these features. There is a family tendency, with some genetic associations. Progression to a diagnosis of epilepsy is more likely to occur in association with neurodevelopmental abnormalities, complex febrile seizures, family history of epilepsy, and longer duration of fever. 

This child presented to the ED with febrile seizure, defined as complex because of the postictal period, as well as hyponatremic dehydration. Laboratory studies were indicative of infection, and other abnormalities improved following fluid hydration. Chest x-ray was negative, and cultures were ultimately negative. The confounding issue in this case was that the child had not been completely immunized, only receiving the first six months of vaccinations. There was concern that she may have acquired pneumococcal pneumonia even in the context of a negative chest x-ray. Even so, she was hemodynamically stable, had no further seizure activity, had no oxygen requirement or signs or symptoms of sepsis. She did not require acute inpatient admission and could have been safely managed at a lower level of care.