Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for a headache, who was brought in by her mother for a new onset seizure. The patient was in her usual state of health until the day of admission when her mother tried to wake her up. She woke up, was responsive, and went back to sleep again. After 2 minutes, her sister went into the room to wake her and she found her seizing. She was extending both of her upper and lower extremities with flexion of both hands and feet, biting her tongue and drooling of saliva and blood. She had no rolling of her eyes but she was staring and not responsive. This episode lasted 2-3 minutes. There was no urinary or fecal incontinence. After that, she was confused, complained of back and neck pain and did not remember anything. Otherwise, there were no similar episodes before, no fever, no travel, no trauma, no sick contacts.
She was brought to the emergency room (ER) and the initial vital signs were a temperature of 36.7 degrees Fahrenheit, heart rate (HR) 120, respiratory rate (RR) 18, oxygen saturation (O2 sat) 97%, and blood pressure (BP) 137/82. She had Glasgow Coma Scale (GCS) of 15 and was described as alert, oriented to person, place and time. Laboratory studies were done and were unremarkable. She was admitted to the pediatric floor with a diagnosis of new onset seizure. The plan was for seizure precautions, neurological checks every (q) 4 hours, electrocardiogram (EKG), Ativan as needed (PRN) and a neurology consult. The neurologist recommended magnetic resonance imaging (MRI) of the head without contrast and a video electroencephalogram (EEG). The patient was monitored and a thorough assessment for the etiology of the seizure was performed. She had a head computed tomography (CT) scan, magnetic resonance imaging (MRI), complete blood count (CBC), creatine kinase (CK), comprehensive metabolic panel (CMP), magnesium (Mg) levels and urine drug screening (UDS), all of which were unremarkable. The head CT scan and MRI of the brain were unremarkable. 36 hours of video EEG showed occasional bursts of irregular generalized spike and wave complexes lasting up to one second seen more frequently during wakefulness than sleep. After the first dose of Keppra, the video electroencephalogram (VEEG) showed much less frequent epileptic discharges overnight. The patient was very anxious and scored 15 on a general anxiety disorder (GAD) questionnaire. Psychiatry was consulted and they recommended follow up in their outpatient clinic. The discharge diagnosis was primary generalized epilepsy. The patient was deemed medically stable and discharged on Keppra 250 milligrams (mg) q 12 hours and with seizure precautions. She was given instructions to follow up with the primary medical doctor (PMD), neurologist and ophthalmologist as an outpatient.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
This patient presented with an isolated episode of seizure activity. Upon admission she had no focal neurological findings, unremarkable laboratory values and a negative head CT scan. The plan at admission was for pediatric neurology consultation and an EEG. While admitted, she did not require any complex or highly technical skilled care. She had a video EEG which did show some positive findings that improved on repeat EEG after starting antiepileptic medication. An MRI of the brain was also done and returned normal. She was observed and had no recurrence of symptoms. Information available to the emergency room (ER) physician at the time of admission documented an alert and oriented patient with normal vital signs, normal laboratory values and a normal head CT scan. These findings would not meet criteria for admission to an inpatient level of care. If at the time of admission, she did not demonstrate altered mental status, new focal neurological deficit, metabolic derangement, recurrent seizure, intracranial process such as bleeding or increased intracranial pressure, admission to inpatient level of care was not medically necessary.
The provided information referenced Milliman Care Guidelines (MCG) Health Pediatric Seizure criteria. Inpatient admission would be indicated for complex febrile seizure, status epilepticus or repetitive seizure not controlled with emergent treatment, brain disorder that requires monitoring or intervention, brain insult like severe trauma, stroke, drug toxicity or withdrawal, or if altered mental status that is severe or persistent, new focal neurological deficit that is severe or persistent, metabolic disorder (i.e. hypoglycemia or hyponatremia) that is severe or persistent, recurrent seizure, outpatient anti-seizure regimen cannot be established (patient cannot tolerate medication or initiation requires inpatient care), need for ongoing IV infusion of anti-seizure medication, central bleeding, hydrocephalus or vasospasm monitoring, increased intracranial pressure or cerebral edema monitoring. Other condition treatment or requiring inpatient admission. InterQual guidelines were also referenced and state inpatient admission required for change in seizure pattern, multiple episodes in 24 hours, sodium between 120-126 or new onset focal finding. The patient did not meet any of these criteria.