Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Seizure-like Activity. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female infant with no significant past medical history born at 38 weeks' gestation via vaginal delivery with pregnancy complicated by maternal ophthalmologic surgery in the third trimester. She was referred to the ED (emergency department) with abnormal movements. She had three separated episodes while lying supine with symmetric extension of all four extremities and fixed gaze. Each episode lasted a few seconds and she cried afterwards. There was no obvious external stimulus prompting the movements. 

The patient's review of symptoms included some cough and nasal congestion but no fevers, no increased work of breathing. Her sister was sick with RSV (respiratory syncytial virus) and parainfluenza infections. Vital signs included temperature 36.9, heart rate 163, respiratory rate 36, and 97% saturation in room air. Examination was significant for active appearance, flat anterior fontanelle, moist mucous membranes, regular heart rate and rhythm, normal pulmonary effort, benign abdominal exam, brisk capillary refill, and non-focal neurologic exam. Differential diagnosis included new-onset seizures, Sandifer's syndrome, and normal startle reflex. Laboratory evaluation revealed significant thrombocytosis (platelets 881K [thousand]), normal WBC (white blood cell) count (10K [thousand]) with lymphocytosis (87%). Head ultrasound and respiratory viral panel were ordered. 

The patient was treated with an IV (intravenous) fluid bolus and admitted for further monitoring and evaluation. Admission orders included Neurology consultation, Tylenol as needed, bulb suction for congestion, routine vitals and cardiorespiratory monitoring, breast milk ad lib, and electroencephalogram. She remained stable throughout the day with no further spells. Respiratory viral panel returned positive for RSV (respiratory syncytial virus). Head ultrasound was unremarkable. EEG (electroencephalogram) was read by Neurology as normal, and she was cleared for discharge home. Repeat CBC (complete blood count) revealed persistent thrombocytosis with platelets 921K (thousand), considered an acute phase reactant. Recommendations included outpatient follow-up. 

No, acute inpatient admission was not medically necessary. 

This young female infant with incidental RSV (respiratory syncytial virus) illness presented to the ED (emergency department) with three episodes of extensor posturing of all four extremities lasting seconds followed by crying. She was supine for all episodes. There was no associated loss of bowel or bladder control, no vomiting, no rhythmic movements. She had no evidence of respiratory distress and no apnea. The differential diagnosis included possible seizure, Sandifer syndrome (a rare complication of gastroesophageal reflux with extra-esophageal symptoms), and exaggerated startle reflex. During the time that she was in the ED (emergency department), she had no further spells. While it was reasonable to monitor this infant as well as perform a limited diagnostic work-up (head ultrasound, metabolic labs, complete blood count, respiratory viral panel due to exposure risk at home), she was overall hemodynamically stable with no cardiorespiratory compromise and no neurologic abnormalities on exam. She did not require acute inpatient admission, and she could have been safely managed at a lower level of care. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.