Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

This case involves a patient who presented to the hospital reporting a new onset seizure. It was noted that the patient had fallen backwards with her arms and legs jerking with frothing at the mouth as witnessed by her father. The father reported that the activity lasted for 1 to 2 minutes. The patient had no history of seizures.  However, the father had a history of epilepsy with onset age of 18 years old. Vital signs noted blood pressure 100/56, temperature of 98.6 F (Fahrenheit), pulse of 88, and respirations of 16. The patient's oxygen saturation was 100%. The patient endorsed nausea and headache. An electrocardiogram noted a nonspecific interventricular conduction delay. A urine drug screen was negative. The patient tested positive for COVID-19.  A urinalysis noted bacteria. The patient reported dizziness with ambulation. She was initially alert and then noted to be sleepy. Adult neurology does not see pediatric patients. Since it was the first onset seizure, they would admit the patient to pediatrics for a neurology consult in the morning. The electroencephalogram was normal.  A magnetic resonance imaging of the brain was unremarkable. There was no further seizure activity. She was cleared for discharge home. She was to have a follow-up with neurology in 5 to 7 days.

Per the referenced sources, an admission for a pediatric seizure is indicated for hemodynamic instability, febrile seizures with focal seizure activity or prolonged seizure of 15 minutes or more, for status epilepticus, for brain disorder, for altered mental status that is severe or persistent, for new focal neurologic deficit and for a recurrent seizure during emergency department or observation care when the patient is not known to have a seizure disorder. In this case, the patient presented to the hospital with reports of seizure-like activity. It was argued that the hospital admission was medically necessary. The patient complained of seizure activity. There was a known family history of seizures. Her COVID 19 testing was positive. The patient required Ativan as needed. The patient required inpatient monitoring needs including seizure precautions, neurochecks, and vital sign checks. Thus, admission was warranted. It was noted that the patient reported dizziness with ambulation. It is also noted that she was initially alert and then sleepy. However, there were no new focal neurological deficits on exam.  While there was a report of the patient appearing sleepy, this was noted after midnight and was likely related to the time and not the reported seizure activity.  The documentation did not detail febrile seizure, status epilepticus, brain disorder, severe persistent altered mental status, new focal neurological deficit, or recurrent seizures that occurred after emergency department or observation level of care. There was no hemodynamic instability.  Thus, the patient's care could have occurred at an observation level of care. As such, the hospital admission was not medically necessary.  Therefore, the denial of an inpatient hospital admission was appropriate and is upheld.

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.