Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

This female child has a past medical history of attention deficit hyperactivity disorder (ADHD) and autism.  The patient presented to the Emergency Department (ED) after being brought in by ambulance from home for seizure activity.  The patient was mostly nonverbal at baseline per her father.  While at home, the patient's father heard a possible thump and the patient was found on the floor, unresponsive, with full body stiffening upper extremity shaking, eyes rolled back; this episode lasted for about 2 minutes. The patient had perioral cyanosis after the incident and her father started cardiopulmonary resuscitation (CPR) for around one minute.  The patient was then drowsy for around 15 minutes and developed episodes of vomiting.  When the patient arrived at the ED, the patient was at baseline. There was no seizure activity on arrival. The seizure type was noted to be grand mal, and the episode characteristics included abnormal movements, eye deviation, general shaking and stiffening and no incontinence; the duration was 1 minute. The context was developmental delay.  There was no recent head injury. The patient's blood pressure was 111/75 and her pulse was 110.  The patient was not in acute distress and was not ill-appearing, toxic-appearing, or diaphoretic.  The patient was alert and oriented to person, place, and time and her mental status was at baseline per the provider. The neurologist was contacted and the patient was recommended for admission for a magnetic resonance imaging (MRI) and electroencephalogram (EEG), and seizure precautions.  The admitting diagnoses were seizure and first-time seizure.  If the patient had another seizure, she was to be started on Keppra.  The patient was to undergo neurologic checks every 4 hours.  The patient's EEG result was normal.  The patient's MRI result was normal.  The patient was to undergo neuro checks.  During the hospital stay, the patient remained hemodynamically stable and had no further seizure activity.
  
As per MCG guidelines for seizure, inpatient admission is clinically indicated for hemodynamic instability; complex febrile seizure; status epilepticus or repetitive seizures not controlled with emergent treatment; 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 persists despite observation care; cardiac arrhythmias of immediate concern; altered mental status that is severe or persistent; new focal neurologic deficit, metabolic disorder that persists despite observation care treatment; recurrent seizure; outpatient anti-seizure regimen cannot be established; cerebral bleeding, hydrocephalus, or vasospasm monitoring; or increased intracranial pressure or cerebral edema monitoring. 

In this case, the patient was at her baseline after arrival to the hospital. There was no seizure activity on arrival. The patient was not in acute distress and was not ill-appearing, toxic-appearing, or diaphoretic.  The patient was alert and oriented and her mental status was at her baseline per the provider.  The patient was recommended for admission for a MRI and EEG, and seizure precautions.  The patient's EEG was normal, and her MRI was normal.  The patient remained hemodynamically stable and had no further seizure activity. Based on this review, the patient's testing could have been completed on an outpatient basis or under observational care.  

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.