Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Body spasms. 
Treatment: Inpatient hospital admission. 
The health plan denied the inpatient hospital admission as not medically necessary. 
The health plan's determination is overturned. 

The patient is a male infant born at 26 weeks' gestation with a three-month Neonatal Intensive-Care Unit (NICU) stay that was taken to the emergency department (ED) with concern for seizures. He was discharged from the NICU three weeks prior, and two days after coming home he began having episodes of stiffening of his extremities lasting about thirty seconds and spontaneously resolving. There was no loss of consciousness; he was feeding well with baseline activity. His vital signs included a temperature of 98.5 degrees Fahrenheit, a heart rate of 168 beats per minute (bpm), and a respiratory rate of 34 breaths per minute. The patient's examination was significant for no acute distress, non-toxic appearance, mild congestion, moist mucous membranes, clear lungs, benign abdomen, and a non-focal neurologic exam. The differential diagnosis was quite broad with possibility for infantile spasms. His head ultrasound was unremarkable. A Neurology consultation was obtained with recommendation for a video electroencephalogram (EEG). The viral panel was positive for adenovirus. He was admitted for further evaluation and management. Admission orders included neurological checks every four hours, lorazepam as needed for seizures, a video EEG, and a Neurology consultation. He slept well overnight and was feeding well every three hours. The video EEG was started. During the morning examination, he started crying with stiffening of all limbs and facial cyanosis despite breathing, with oxygen saturation of 90-92 percent (%) on room air. There was no eye deviation. The episode lasted less than a minute with no post-ictal period. It was captured on video and marked on EEG. Pediatric Pulmonology and Pediatric Surgery (inguinal hernia) were consulted. He had no abnormal movements overnight. He continued to do well. MRI was performed and was interpreted as unremarkable. The video EEG revealed mild diffuse encephalopathy with possible bilateral cerebral dysfunction. 
At issue is the medical necessity of the inpatient emergency admission. 
I overturn the health plan's determination, in whole. 
The acute inpatient hospital admission was medically necessary. 

The differential diagnosis of first-time afebrile seizure activity is quite broad, and includes head trauma, abuse, toxic ingestion (intentional or accidental), infection, elevated intracranial pressure, and anatomic abnormalities. Initial evaluation must include a complete history and comprehensive physical examination to identify possible life-threatening causes of seizures. Characterization of the type of seizure is also important, differentiating between febrile and afebrile, focal and generalized. Risk for seizure recurrence is greatest within the first six months. This ex-premature male infant presented with episodes of stiffening concerning for seizure activity. After initiation of the patient's work-up in the ED, he was admitted for further management. He had an episode of stiffening associated with cyanosis and desaturation during examination on the second hospital day. The video EEG was in process during the episode. The final interpretation was concerning for bilateral cerebral dysfunction with mild diffuse encephalopathy. MRI brain imaging and an echocardiogram were both obtained and were unremarkable. He had no further episodes in the hospital and was discharged with multiple outpatient evaluations pending. This level of care and intervention is most consistent with acute inpatient admission. Further, he was born extremely prematurely, was medically fragile, and was just past term when he presented to the ED for evaluation.