Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure/Tics.
Treatment: Inpatient hospital stay.

The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination. 

The patient has a known history of motor and vocal tics who presented on with increasing intensity and frequency of such. Initial vital signs revealed a temperature of 98.4Fahrenheit, heart rate 88, blood pressure 116/64, respiratory rate 18, peripheral capillary oxygen saturation 97% on room air. Initial examination documented as alert and oriented without focal neurological deficits. Initial laboratory testing was unremarkable. A computed tomography (CT) scan of the head was unremarkable. The patient was placed in the hospital thereafter with an impression of provisional tics disorder, Tourette syndrome, or partial seizures. Treatment plan included a video electroencephalogram (EEG) and neurology consultation. Pediatric neurology consultation was obtained who recommended the patient follow-up as an outpatient if the video EEG was normal. The video EEG was normal after 12 hours. Her tics remained stable, and no seizure-like activity was observed. The patient was discharged without further intervention or prescriptions. 

Acute inpatient level of care was not indicated as medically necessary for the entire admission.

The patient has a history of motor and vocal tics who presented with such, including eye rolling. Upon arrival, she was alert and oriented. Pediatric neurology consultation was obtained who recommended no initiation of medication and outpatient follow-up. The patient was discharged the day after presentation.

The American Academy of Family Physicians (AAFP) published guidelines regarding the evaluation and management of seizure, mainly first known episode. They note that the patient history and physical examination should focus on events directly preceding the seizure, the number of seizures in the past 24 hours, the length and description of the seizure, focal aspects (e.g., unilateral movements, eye deviation, head turning to one side), length of the postictal period, and the neurologic examination. This allows proper categorization as well as etiology identification and recurrence risk. Thereafter, in agreement with the American College of Emergency Physicians (ACEP), a Computed tomography of the head with and without contrast should be performed to look for structural lesions. Both the AAFP as well as the ACEP note that stable patients who have returned to baseline neurologic status in the emergency department may be discharged and scheduled for outpatient neurology if follow-up can be ensured. Additionally, laboratory tests can be performed but should be tailored to the individual patient and driven primarily by findings from the history and examination (e.g., glucose level in a diabetic, liver function tests/ammonia in a cirrhotic).

Moreover, clinical indications for acute inpatient level of care were not met. The patient did not have hemodynamic instability, status epilepticus, brain disorder (e.g., tumor, edema, hydrocephalus, encephalitis, meningitis) that requires monitoring or intervention available only at the inpatient level of care, brain insult (e.g., severe trauma, stroke, drug toxicity, withdrawal) that requires monitoring or intervention available only at the inpatient level of care, cardiac arrhythmias of immediate concern, new onset seizure (i.e., first seizure) without return to baseline neurologic function within 30 minutes after seizure, persistent altered mental status, new focal neurologic deficit (e.g., post seizure), metabolic disorder that persists despite observation care treatment, recurrent seizure, antiseizure medication that requires initiation at an inpatient level of care, cerebral bleeding, or increased intracranial pressure.