Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-epileptic seizures

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld. 

This patient is a female child with a past medical history of seizures and migraines.  The patient presented to the emergency department. The patient had an aura and told her mom she was going to have a seizure. The patient seized with her mouth to one side and twitching with all body shaking for approximately 1.5 minutes.  The patient was postictal for a long time.  The patient had some cyanosis and frothing in the mouth.  The neurologist said she was not epileptic and she had minor seizures after an electroencephalogram (EEG).  The patient also had a history of anxiety. The seizures were mild since the age early childhood and she was not on medications. The patient's blood pressure was 124/57 and her heart rate was 97.  
The patient's pain was rated 8/10 and she complained of pain and discomfort with migraines in both temples.  The physical examination revealed the patient was awake, alert and cooperative.  The history and physical indicated the patient had 10 minutes of delirium before returning to baseline.  The patient had a history of abnormal random limb movements for which she was always aware of and they would last a couple of seconds.  Recently, she had had generalized shaking for which she had been aware of except for the last 2 episodes.  The patient reported headaches after every episode of abnormal limb movements and noted that the episodes occurred when she did not have enough sleep.  There was no blurred vision.  The patient was in no apparent distress.  The patient was afebrile and there were no signs of infection. The patient was admitted.  The plan was to perform a video-electroencephalogram (EEG) overnight which was normal.  It was documented that the seizure like activity was most likely psychogenic non-epileptic seizures.  The patient was discharged in stable condition.

According to current literature a pediatric patient may be admitted to inpatient services for seizures when there is evidence of hemodynamic instability, a complex febrile seizure, the patient is status epilepticus or repetitive seizures are evident that are not controlled with emergent treatment.  Furthermore, an admission may be noted when there are cardiac arrhythmias of immediate concern, altered mental status that is severe or persistent or there is a metabolic disorder or new focal neurologic deficits.  Within the documentation none of the above was noted.  The documentation detailed the patient had a history of seizures and migraines and was found to have non-epileptic seizures due to the anxiety. The documentation indicated the patient had one witnessed seizure and no further events.  The documentation does not detail a failure of lower levels of care or any of the above indications.  No treatments were initiated as a result of the admission. 

Therefore, as it appeared the patient was clinically stable enough to receive services at a lower level of the health plan acted reasonably with sound medical judgment in the best interest of the patient.

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