Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Febrile seizure.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is Upheld.

The patient is a toddler male child that presented to the emergency department (ED) with a new-onset seizure lasting less than ten minutes. He had been ill for two days with diarrhea, decreased intake, and fever treated with Tylenol. The patient's vital signs included a temperature of 40.4, a heart rate of 186, and a respiratory rate of 32. The examination was significant for a fatigued appearance with mild distress, moist oral mucosa, clear nasal discharge, clear lungs, tachycardia, and a non-focal neurologic exam. Shortly after arrival, he had a second seizure associated with hypoxia (desaturation to 50's resolved with supplemental oxygen) and brief bradycardia (90's improved with bagging). He was treated with Ativan with cessation of seizure activity after about ten minutes. He was also given ibuprofen for fever. A full septic work-up was undertaken including a lumbar puncture. Head computed tomography (CT) and chest x-ray were both obtained, and both were negative. Rapid COVID19 (coronavirus disease), respiratory syncytial virus (RSV), and influenza A tests were negative. Venous blood gas was consistent with combined respiratory and metabolic acidosis. A preliminary cerebral spinal fluid (CSF) evaluation was not consistent with a bacterial infection. He was given a dose of ceftriaxone, Keppra load, and normal saline bolus before transfer to the pediatric intensive care unit (PICU). After two days in the pediatric intensive care unit, he was transferred to the pediatric floor. He was stable in room air, and on intramuscular ceftriaxone due to lost intravenous access. The antibiotic was discontinued after 48-hour negative cerebral spinal fluid (CSF) cultures. He was deemed stable for discharge to follow up with his pediatrician in two to three days.

The inpatient admission was not medically necessary.
Febrile seizures occur in up to five percent of children ages six months to five years. Febrile seizures are characterized as simple or complex. Simple seizures are generalized, lasting less than 15 minutes, with only one occurrence in 24 hours and no post-ictal period. Complex seizures deviate from one or more of those features, lasting longer than 15 minutes, having more than one seizure in 24 hours, with a post-ictal period, and/or presenting as focal rather than generalized. Initial evaluation of a patient with febrile seizure includes history, examination, and diagnostic testing to identify the source of fever. Most febrile seizures are self-limited. Those lasting longer than five minutes should be treated with the administration of a benzodiazepine such as Ativan, Valium, or Versed. The use of preventive medications such as anticonvulsant medications or intermittent benzodiazepines must be considered both from a benefit and risk of adverse event perspective. In general, hospitalization is not necessary for febrile seizures. In the case of this young child, he presented with initial features of the simple seizure (generalized, less than 15 minutes, no post-ictal period). But with the occurrence of a second seizure in the emergency department requiring treatment with Ativan, this was now considered complex febrile seizure activity. Because of the high fever, a full septic work-up was undertaken to rule out bacterial meningitis. He was given a dose of antibiotic pending cerebral spinal fluid (CSF) culture results. While it was reasonable to continue monitoring him in the hospital setting for seizure recurrence and progressive signs of serious bacterial infection, he was overall hemodynamically stable with no reported neurologic deficit and no evidence of impending sepsis. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.