Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This case involves a child who presented to the hospital post-seizure.  The patient had been asked a question in school and had gaze preference to 1 side, started walking in circles, and then fell into full body convulsions for reportedly 3 minutes.  Upon emergency medical service arrival, the patient was postictal.  In triage, the patient was alert, not verbally responding, and following commands.  The patient hit their head during the episode.  There was no known history of seizures.  Upon arrival, the patient appeared better than when at the school but was still not at baseline.  Of note, the principal asked for safety check.  There was evidence of synthetics with possible marijuana oils in the patient's bag.  Vital signs noted temperature of 95.7 Fahrenheit, heart rate of 82, respirations of 16, oxygen saturation of 99% on room air, and blood pressure of 137/71.  There was a plan for laboratory testing, consult with neurology, and admit for further observation and evaluation.  Urine tox screen was positive for tetrahydrocannabinol.  Laboratory results noted white blood cell count of 8.7, hemoglobin of 14.4, hematocrit of 43.5, and platelet count of 317.  The patient was admitted for observation to the pediatric floor.  The patient reported smoking marijuana twice a month with the last used being the previous day.  The patient's parent reported that the patient had been feeling tired lately.  Computed tomography of the head and magnetic resonance imaging of the brain were unremarkable.  The electroencephalogram was unremarkable.  It was felt that the patient's seizures could be due to recreational drug use.  The patient was observed overnight with no acute events.  There was a plan for discharge.

It was stated that the full hospital admission was not considered medically necessary.  The documentation did not identify that the patient had repeated seizures or other severe problems including high fever or brain tumor that would support the full admission.  The patient had new onset seizure that lasted approximately 3 minutes.  The patient was postictal afterwards with lethargy, confusion, and was nonverbal.  Although there was some improvement, the patient did not return immediately to baseline as reported by the patient's parents.  Ongoing skilled assessment of the patient's neurological status was medically appropriate to ensure a positive outcome.  The patient's history of sudden onset seizure activity with head trauma and the unclear etiology of the episode required further investigation.

It was argued that the full hospital admission was medically necessary for the patient.  The summary of the patient's hospitalization was detailed with reference to Milliman Care Guidelines in support of full admission. The patient had altered mental status that was severe or persistent.

On arrival, the patient was postictal.  Although the patient had altered mental status, the documentation did not support that this lasted beyond observation level of care.  While there was reported drug use, the documentation did not reveal symptoms of withdrawal or toxicity.  There were no new neurological deficits or metabolic disorders that persisted despite observation time frame.  There was no evidence of febrile seizure or status epilepticus.  Observation level of care would have been appropriate for the patient but not full inpatient admission.  As such, the denial of coverage for full hospital admission was appropriate and is upheld.

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.