Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncopal Episode
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a medical history significant for syncopal episodes with anoxic seizures diagnosed and treated with zonisamide. He experienced an unwitnessed seizure lasting approximately one to two minutes, about a week after running out of medication. He was incontinent of urine and was postictal for about five minutes. He had abrasions along the right side of his face and on his right hand/knuckles. He was taken to the emergency department (ED) via Emergency Medical Services (EMS) for evaluation. Vital signs included a temperature of 36.7 degrees Celsius, heart rate 86, respiratory rate 20, and blood pressure 114/60. The examination was significant for contusions on the right side of his face mainly on his cheek and forehead, mildly decreased breath sounds on the right with no wheezing, and a non-focal neurologic exam. Neurology was contacted with recommendations to treat with 2 milligrams (mg) lorazepam and 200 mg zonisamide.
A non-contrast head computed tomography (CT) scan and chest x-ray were ordered. His wounds were irrigated and treated with topical antibiotics. A head CT scan revealed mild extracranial soft tissue swelling and possible tiny subgaleal hematoma in the right frontal scalp and a comminuted nondisplaced fracture of the left nasal bone of uncertain age. Pediatric Surgery was consulted with recommendations to admit for supportive treatment. Prior to transfer, he was given a normal saline bolus. Admission orders included nothing by mouth, intravenous (IV) fluids, pain control, IV antibiotics, Keppra and zonisamide, and frequent neurological checks. Oral Maxillofacial Surgery was consulted with recommendations to reduce the nasal bone fracture in the outpatient setting, treat with Keflex for seven days, and provide pain management. Social Services was consulted because of delays in obtaining medication refills. He had no further seizure or syncopal episodes and was deemed stable for discharge. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary. This male teen diagnosed with seizures versus convulsive syncope (reflex anoxic seizures), complicated by medication non-compliance or lack of availability, presented to the ED after suffering an attack with associated closed head trauma. Imaging revealed a nondisplaced nasal fracture and question of a small subgaleal hematoma. He was admitted for IV hydration, IV antibiotic therapy for the nasal fracture, wound care, and administration of anticonvulsant medications (zonisamide, Keppra). During his hospital stay, he was evaluated by Neurology, Oral Maxillofacial Surgery, Pediatric Surgery, Pediatrics, and Social Services. Neurologic checks were performed every four hours in addition to antibiotic administration and IV hydration. Despite the short duration of his hospital stay, the level of care that was administered was most consistent with acute inpatient management. A lower level of care would not have been sufficient or appropriate in this case.