Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Seizure
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was medically necessary.

The patient is a young female child.  She presented to the ED via EMS with three-day history of vomiting and diarrhea.  She was standing in the kitchen in the morning, noted to be unsteady on her feet, then went limp and fell with one arm shaking for about ten seconds, unconscious for one to two minutes.  She was noted to have tactile fever but had not received anti-pyretics that morning. 

The patient's vital signs included temperature 36.4, heart rate 143, respiratory rate 26, and 100% oxygen saturation in room air.  Examination was significant for no acute distress, no focal deficits or ataxia, no scalp or neck injury, moist mucous membranes, no meningeal signs, clear lungs, regular heart rate and rhythm, non-tender abdomen, and good perfusion.  Cloudy urine was obtained by bladder catheterization and sent for urinalysis and culture.  Pediatric Neurology was consulted.  She appeared well but was refusing to drink anything.  Per the patient's mother, the patient had not returned to baseline.  Plans were made to continue IV hydration and admit for EEG the next day. 

While in the ED, the patient had a second seizure described as tonic-clonic and lasting two minutes.  She was given a dose of Ativan, but the seizure had already stopped.  Her oxygen saturation dipped into the 80s during the seizure.  Additional diagnostic testing was then ordered, including CT scan.  Laboratory testing revealed viral panel positive for enterovirus/rhinovirus, unremarkable urinalysis (concentrated urine, ketonuria), mildly elevated AST (aspartate aminotransferase) (54), mild hyponatremia (135), mild hypoglycemia (60), metabolic acidosis (17), unremarkable CBC (complete blood count), cultures pending.  CT scan was unremarkable.  She had been treated with two normal saline boluses prior to admission for further management of seizure and dehydration. 

Admission orders included IV fluids, regular diet as tolerated, Neurology consultation, EEG, vital signs every four hours, cardiac monitor, and follow-up cultures and stool studies.  She was seen by Neurology the same day, with recommendations for EEG, ongoing medical management of dehydration, and Ativan for emergencies overnight. The EEG was completed the following morning.  She had no further episodes of diarrhea or vomiting, and had no further seizures.  She had returned to her baseline level of activity.  The EEG was interpreted as normal.  Neurology recommended CPR training for the mother and follow-up in the outpatient clinic in two to three weeks.  She was subsequently deemed stable for discharge, to follow-up with her pediatrician in one week. 

This young female child presented to the ED with a simple, presumably febrile or infection-related, seizure.  She did not return to neurologic baseline and had a second seizure while in the ED.  In addition, she refused an oral challenge while in the ED, with signs and symptoms consistent with dehydration (concentrated urine, metabolic acidosis).  She was admitted with complex febrile (infection-related) seizure and dehydration.  Because she was now in the category of patients with complex seizure, neuroimaging and EEG were appropriate.  She also required ongoing rehydration with demonstrating that she could take in sufficient fluids to sustain herself.  While she recovered within the 24-hour admission, the level of care that she received was most consistent with acute inpatient management.  The hospital stay was, thus, medically necessary as acute inpatient.