Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure-Like Activity/Syncope

Treatment:  inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld.

This infant was brought by ambulance to the emergency department due to decreased responsiveness for several minutes after exertion, loss of consciousness and, in addition, tongue biting and urinary incontinence.  The documentation indicated the patient had complete resolution of symptoms upon emergency medical services (EMS) arrival.  The documentation indicated upon physical examination he was alert and awake and per mother was at baseline mental status.  There was no signs of dehydration and the vital signs revealed temperature 96.2 with pulse of 125.  Oxygen saturation was 99% (percent).  The electrocardiogram (EKG) was within normal limits per pediatric cardiology.  It was recommended he undergo laboratory diagnostic studies.  The decision was also made to admit the patient for a further work-up.  The patient was admitted to the pediatric unit.  He did undergo a neurology consultation and it was recommended he undergo a video electroencephalogram (EEG).  The study was negative for any seizure activity.  Pediatric cardiology was also consulted.  The documentation indicated the continued with treatment and remained stable.  He was initially placed under seizure precaution.  Laboratory studies were normal with the exception of an elevated CK (creatinine Kinase).  He was also recommended throughout the stay that the patient undergo an MRI (magnetic resonance imaging).  The patient's mother detailed they would undergo an MRI as an outpatient service.  Given the continued stability with no further adverse events, the patient was discharged with instruction to follow-up.

According to the guidelines provided by the InterQual, the acuity of this case is considered to have required observation as the patient had altered mental status. 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 video EEG and EKG were performed without abnormality. No other interventions were necessary. The patient was described as interactive and was able to be discharged. 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. Within the documentation it was noted the patient presented with altered mental status speech, his symptoms resolved after some hydration and no other treatments. However, 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 elected to self-discharge. The requested inpatient admission would not be the most appropriate level of care and therefore, the health plan acted reasonably with sound medical judgement.

Based on the above, the medical necessity for the inpatient level of care is not substantiated. The insurer's denial is upheld.