Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient Hospital Admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

This case involves a female who has a history of bronchopulmonary dysplasia with gastroesophageal reflux disease (GERD) status post necrotizing enterocolitis, ileocecal resection, spastic cerebral palsy, and cortical blindness. The documentation indicated she was brought to the Emergency Department (ED) due to a 2-day history of focal seizures. It is noted that the patient was recently admitted with similar complaints. The documentation indicated the prior infectious work-up was unremarkable. The documentation indicated since the prior discharge the patient's mother has noticed multiple episodes of left eye deviation and staring that has self-resolved. The patient was also more tired than usual and sleeps more. She has had an increase in Trileptal. The physical examination revealed the patient was active and interacting with her mother. The patient was able to move all 4 extremities without tremor or ataxia. The physician indicated the patient does have a past medical history that includes focal epilepsy with increased seizure frequency in the setting of fever as well as decreased activity and unsteadiness. The examination did reveal the patient was active without episodes of eye deviation. It was recommended she undergo laboratory studies and a pediatric neurologic consultation. The recommendation was made to admit the patient. The documentation indicated she was admitted for further evaluation and treatment. There were episodes of gaze deviation and head turning with lethargy noted. An electroencephalogram (EEG) was done and the bifrontal spike-wave discharges with rare sharp waves. Medication was titrated to improve her seizure control. The documentation indicated she did not any further significant adverse events while hospitalized. The patient was discharged with instruction to follow-up.

According to the guidelines provided by the InterQual 2019, the acuity of this case is considered to have required observation as the patient with a transient neurologic of unknown cause although pseudoseizures are suspected. Upon arrival, the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the stay. Precautionary testing with computed tomography (CT) and EEG were performed without abnormality. No other interventions were necessary. The patient was described as interactive and at baseline upon discharge. The patient did not require an escalated level of care.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. The submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient was back at his baseline and was discharged after 3 days. The requested inpatient admission would not be the most appropriate level of care and therefore, the prior denial remains upheld.

The insurer's denial of coverage for the inpatient hospital is upheld. Medical necessity is not substantiated.