Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure-like Movement.

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 evaluation.  The mother reported that she noticed intermittent jerking type movement x4 days described as an extension of the patient's bilateral arms and rapid breathing lasted 1-2 seconds x 5-6 times, after which the patient returns to their usual self, laughing and seemingly very excited after the event. Despite having multiple episodes of seizure-like movement, the patient's electroencephalogram (EEG) remained normal.  It was reported that the child started on whole milk after which they started having episodes.  Vital signs on presentation were temperature (T) 98.5 Fahrenheit (F), heart rate (HR) 104, respiratory rate (RR) 22, and oxygen (O2) saturation 100% on room air (RA). Interventions included: Ativan intravenous (IV), seizure precautions, neuro consultation, Tylenol as needed, EEG, and pending magnetic resonance imaging (MRI) results. The patient has no significant medical history. The mother denies having loss of consciousness (LOC), eye rolling, tongue biting, frothing at the mouth, tonic/clonic movements, postictal state, urinary incontinence, respiratory distress, decreased oral intake, or decreased activity.  There is no family history of epilepsy or seizure disorders. Glucose, c-reactive protein (CRP), and comprehensive metabolic panel (CMP) were unremarkable and there was a benign physical examination. The provider noted the patient was clinically stable but would require admission to pediatrics for further work-up.

Video EEG monitoring demonstrated a normal result, with a well-organized and symmetrical awake and sleep EEG. No epileptic activity was seen.

On hospital day 2, the provider indicated that the patient had multiple episodes of similar movements overnight.  Otherwise, the parents reported that the patient was doing well, had a good appetite, and was voiding and passing stools at their baseline.  

The following day, the provider indicated the patient continued to have multiple sudden brief involuntary abduction of arms which has not increased or decreased in frequency. No epileptic activity was seen on the EEG. The provider indicated possible nonpileptic behavioral or involuntary movement. The video EEG was discontinued. The case was discussed with the pediatric neurologist who recommended that the patient follow up at their office. The plan was for an MRI of the brain as an outpatient with an appointment with the pediatric neurologist. 

Milliman Care Guidelines (MCG) indicate inpatient care admission for pediatric seizure is indicated for 1 or more of the following: Hemodynamic instability; febrile seizure and 1 or more of the following: child older than 5 years, focal seizure activity, prolonged seizure of 15 minutes or more, more than 1 seizure within 24 hours, suspicion for meningitis; status epilepticus; 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 or that persist despite observation care; altered mental status that is severe or persistent; new focal neurologic deficit; metabolic disorder that persist despite observation care; Recurrent seizure (during emergency department for observation care) and outpatient antiepileptic regimen cannot be established.  

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 full hospital admission is not substantiated.