Appeal type: Medical necessity
Decision: Upheld

Seizure 
Inpatient Hospital

The patient is a male with no significant past medical history who presented with a seizure like episode and left ear pain and discharge. Mother reports he went to the swimming pool and was outside with no meal/fluid intake for more than 12 hours and after returning home complained of feeling hot and was sweating so mother put some cold water on his face. Later he said he was unable to hear and not able to move his jaw. While on the couch he became unresponsive, his eyes rolled back, and he started to have bilateral jerky movement of his body. 911 was called and they applied cooling measures and gave intravenous fluids (IVF) en route to emergency room (ER). By the time he arrived at the ER he was afebrile, with mild tachypnea and responsive to painful stimuli but not verbally responsive. Once the patient regained consciousness he was back to baseline. There is also a history of left ear pain for 1 week that had been progressively worsening. He was experiencing decreased hearing and on the day of presentation, ear discharge. He denies fever, trauma, medications, drugs, rash, vomiting, diarrhea, weakness, palpitations, tinnitus, headache, abdominal pain, numbness, diplopia, altered vision, tongue biting or sphincter incontinence. He was admitted to the pediatric floor for heat exhaustion versus (vs). convulsive syncope vs seizure. On admission exam vital signs were stable and his left ear was found to have serosanguinous discharge, tenderness with pinna movement and to palpation in the mastoid area. There was no swelling or erythema over mastoid. There was erythema and white discharge in ear canal, unable to visualize tympanic membrane. Neurologically he was active, alert, oriented to time/person/place. Good tone and strength, normal gait. The urinalysis (UA) with specific gravity (SG) 1020, neg ketones, trace protein and the urine drug screening (UDS) was positive for cannabinoid. The computed tomography (CT) head revealed soft tissue filling the left external auditory canal extending to the tympanic membrane which appeared to be more fluid like than normal cerumen and may be indicative of pus and infection. Neurology and ear, nose, and throat (ENT) consults were ordered. Cardiology consult was called and an echocardiogram (ECHO) was ordered. He was also diagnosed with left otitis externa by ENT and was treated with 3 doses of Ceftriaxone and then placed on Ciprodex drops to complete 1 week of therapy. The cardiologist reported a normal ECHO and recommended if the high BP persisted as outpatient when he is not acutely ill, he should be referred for BP assessment. EEG returned normal and no medication was recommended. At issue is the medical necessity of the acute inpatient admission. The health plan's determination of medical necessity is upheld. The requested health service/treatment of Inpatient Hospital Stay was not medically necessary for this patient. This patient had 3 diagnostic considerations that needed to be addressed and none of them required inpatient level of care to be managed safely. Firstly, this patient presented with history of possible seizure activity prior to presentation. By the time decision was made to admit the patient, he was in stable condition and back to baseline. Admission is not medically necessary if the patient no longer has altered mental status and a normal neurological exam after a period of observation in the ER. There was also suspicion of possible heat stroke or heat related illness but by the time he presented to the hospital his temperature was normal and his laboratory studies did not support any significant signs of dehydration or known complications of heat stroke such as electrolyte aberrations, acute liver and/or kidney injury to name a few. His other concern was ear pain and left ear drainage which had been ongoing for a week prior to presentation. He did not have any physical or radiological findings to support a diagnosis of mastoiditis which would need IV antibiotics. He was seen by ENT and was diagnosed with otitis externa which is treated topically with ear drops. For this, he would not need to be hospitalized. Lastly, he was noted, as the hospitalization progressed, to have episodic hypertension. He did not have hypertension at the outset nor was it persistent during his hospitalization. By the end of the stay, his pressures normalized without intervention. Inpatient level of care would not be needed to treat or assess his asymptomatic episodic elevations of blood pressure. He was described as stable < 24hrs into the hospitalization with a normal neurological exam and he was eating and drinking well. He had an echocardiogram as well as an EEG during the hospitalization. For all of the concerns he could have been evaluated at a lower level of care.