Appeal type: Medical necessity
Decision: Upheld

Diagnosis: seizure

Treatment is an inpatient admission 

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

This case involves a child who presented to the emergency room with reported seizure-like movements. According to the patient's mother, the patient was washing her face prior to arrival and had a brief period lasting around 1 minute during which time her eyes rolled back, her body tensed up, and she was shaking and unresponsive. After being lowered to the ground, the patient's symptoms resolved spontaneously. No other symptoms were documented. She had no past medical history noted as per the medical records report. Initial laboratory studies were remarkable for a potassium level of 3.1 with a CT (computed tomography) of the head demonstrating no acute intracranial abnormalities. The patient's mother denied any head trauma, although the patient reported hitting her head forcefully against a bumper car ride at an amusement park a week prior. The patient was administered potassium chloride and sodium chloride at 72 mL (milliliters)/h (hour) intravenously. 

According to the Milliman Care Guidelines (MCG), admission for inpatient care for a pediatric patient who has reportedly had a seizure includes: those who are hemodynamically unstable, have had a febrile seizure, if they are status epilepticus, and brain disorder that requires monitoring or intervention available at an inpatient level of care, and the etiology requires monitoring or intervention available only at an inpatient level of care or that persist despite observation care, when there is altered mental status that is severe persistent, with no focal neurologic deficit procedure, for those who have a metabolic disorder that persist despite observation care, when there are recurrent seizures, when outpatient antiepileptic regimen cannot be established, when there are cerebral bleeding, or increased intracranial pressure or cerebral edema monitoring needed. MCG also indicates that observation care is an option for those patients who have vital sign abnormality, if they have had a first seizure with no prior diagnosis of a seizure disorder, nonspecific etiology the require short-term observation, treatment, or correction can be utilized, no medication has been initiated or adjusted requires brief observation, or when the patient has altered mental status upon postictal presentation to the hospital.  

Based upon the provided information, observation care would have been appropriate to address the patient's condition. The patient was noted to have had only the initial seizure at home, with no further seizure activity documented. She had no other significant abnormalities noted upon her assessment in the emergency department. While she received treatment for abnormal potassium levels, there were no other significant abnormalities noted to warrant inpatient care. 

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 services is not substantiated.