Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient emergency admission
The health plan denied the inpatient emergency admission.
The health plan's determination is upheld. 

The patient is a male infant who was admitted for evaluation of abnormal leg movements. He was born at 39 weeks gestation and was healthy as a newborn. One week prior to admission, he began to have intermittent abnormal movements of his legs, consisting of extension of the legs, followed by brief periods of leg shaking. The spells of leg movement occurred multiple times per day and had a duration of less than 10 seconds each time. The baby was otherwise well. He was eating well, had normal urine output, and had normal bowel movements. His parents took him to the emergency room for evaluation, where a decision was made to admit him to the hospital. At the time of admission, his vital signs were normal, and his physical examination was normal. Laboratory testing in the emergency room, including a basic metabolic panel, complete blood count, and thyroid function test were normal. A head ultrasound was also normal. He was admitted to the hospital, where he was seen on consultation by the pediatric neurology service, who recommended an electroencephalogram (EEG) and magnetic resonance imaging (MRI) of the brain. The EEG showed excessive sharp waves, which were thought to reflect possible dysmaturity of the brain. During the EEG monitoring, multiple spells of leg movements were captured, and the EEG showed no epileptiform activity during those spells. The baby was also seen by the genetics service, who recommended a chromosomal microarray. In addition, the baby was seen by the ophthalmology service, who noted a normal exam and no cherry red spot. An MRI scan of the brain was normal. Throughout the hospitalization, the patient remained healthy and seizure-free. He had multiple episodes of leg movements, none of which were associated with any EEG abnormality. He was discharged to home.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient admission was not medically necessary for this patient. The patient at the time was a baby who was having frequent spells of abnormal leg movements. He was otherwise entirely well. Evaluation of this child could have been completed with an outpatient EEG. Admission of this child for a prolonged EEG and MRI scan was not medically necessary.
Neonatal clonus of the legs is very common in full-term healthy newborns. These movements, which consist of rapid clonic movements of the legs or ankles are due to the normal immature state of the newborn's central nervous system. In the absence of any other worrisome findings, clonic movements of the newborn's legs can be considered a normal finding. If a treating physician is concerned that the clonic movements are due to seizure activity, then an outpatient EEG can be obtained, which can quickly and reliably determine whether the movements are epileptic or not. The patient had neonatal clonus. If there were still concerns that the movements reflected epileptic activity, then they could have obtained an outpatient EEG. Therefore, the inpatient admission was not medically necessary.