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 emergency department for seizure-like activity. The report stated that she was in school, sitting down, when her eyes began to twitch during which she was conscious at that time. She reported associated blurry vision that lasted 1 to 2 seconds whereupon her whole body began shaking. She could hear others around her throughout the episode but cannot remember what happened next. The school nurse called emergency medical services (EMS) when the episode occurred with claims that the patient continued to twitch until she was medicated by EMS. After the event, the patient seemed confused and groggy per her mother's report. The patient had no significant past medical history but was noted to have paralysis in the right arm per emergency department report. A stroke code was called, and a computed tomography (CT) and CT angiography (A) of the head were done, both of which were unremarkable. Electrocardiography was also unremarkable and laboratory testing was normal. Venous blood gas showed respiratory acidosis with high carbon dioxide (CO2), low potential hydrogen (pH), and normal bicarbonate. Reports indicated that the patient's episode was most likely resembling tonic-clonic seizure. She was admitted to video electroencephalogram (VEEG) monitoring and magnetic resonance imaging (MRI).  No further seizure-like activity was noted on physical examination during the hospital course, and she remained at baseline throughout the hospital course. The patient remained on inpatient status until discharge.  

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The Milliman Care Guidelines state that in order to meet the criteria for inpatient care, there must be documented evidence of 1 or more the following to include hemodynamic instability, febrile seizure, status epilepticus, a brain disorder that requires monitoring or intervention available only at inpatient level of care, etiology that requires monitoring or intervention available only at inpatient level of care with that persists despite observation care, altered mental status that is severe or persistent, new focal neurologic deficit, and metabolic disorder, recurrent seizures, outpatient antiepileptic regimen that cannot be established, cerebral bleeding, hydrocephalus, or vasospasm monitoring requirements, or the need for increased intracranial pressure or cerebral edema monitoring. Alternative levels of care include observation. This includes those patients who had a first seizure with no prior diagnosis of a seizure disorder.  

The documentation provided for the review noted that the patient had no past medical history significant for a seizure disorder. She did not satisfy the criteria for inpatient care based upon the provided information and could have had her care rendered safely and effectively on an observational basis to include medication administration and further work-up. 

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 hospital admission is not substantiated.