Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Acute inpatient stay
The insurer denied coverage for the acute inpatient stay.
The denial is upheld.

This is a female pediatric patient who was brought into the hospital with a chief complaint of seizures. The documentation indicated that the patient was brought in by the ambulance as a transfer from another facility after she had a seizure at home and two at the transferring hospital. The patient had a history of respiratory syncytial virus (RSV) infection requiring an intensive care unit stay. The patient was seen due to seizure-like activity. 

While the patient's mother was changing the patient's diaper, the mother noticed that the patient's upper and lower extremities became stiff. The patient's neck was also hyperextended along with deviation of her eyes to the right. The patient did not have a loss of consciousness; however, she was not responding. The episode lasted approximately 1 minute. A full sepsis work-up was performed at the transferring hospital prior to transfer. The documentation indicated that the patient had no fever, vomiting or rash. Upon physical examination, it was noted that the patient would cry with tears and was consolable by her mother. The patient was able to nurse. 

The recommendation was made to undergo multiple laboratory diagnostic studies. The patient was well-appearing. There was no seizure-like activity noted. The full sepsis work-up was performed and the only significant finding was large leukocytes in the patient's urine with 20 white blood cells. It was recommended that the patient be treated with ceftriaxone. Neurology also recommended loading the patient with Keppra. The patient was admitted to undergo a video electroencephalogram (EEG) and a magnetic resonance imaging (MRI) of the brain. Both the patient's MRI of the brain and video EEG came back with normal results. The patient's antibiotic was discontinued on the second day of hospitalization. The patient was continued with treatment and monitoring. Given the lack of significant adverse events, the patient was discharged on day 4 of admission with instructions to follow-up as outpatient. It was also recommended that the patient continue with Keppra on an outpatient basis.

Milliman Care Guidelines (MCG) indicates that the goal length of stay for a pediatric patient with a seizure is ambulatory or 1 day. Admission would be appropriate for a patient who had status epilepticus or repetitive seizures not controlled with emergent treatment, hemodynamic instability, brain disorder, cardiac arrhythmia of immediate concern, a new focal neurologic deficit, or altered mental status that is severe or persistent. In this case, the records submitted for review indicated that that the patient was hemodynamically stable. The patient was not noted to have repetitive seizures. The patient's diagnostic studies that were performed could have been performed on an outpatient basis. The records do not support that the patient could not have been treated at a lower level of care, such as observation. As such, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient stay should be upheld. The medical necessity is not substantiated.