Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history significant for a febrile seizure who presented with a fever and seizure. The patient was in her usual state of health until the morning of admission when the patient was sleeping with grandmother. The grandmother felt the patient was warm and noticed drooling from patient's mouth and eye rolling that lasted around 30 seconds. The patient was responsive and the mother denies stiffness or rhythmic movements. 

Her temperature (T) was measured in the ear and was 102.9 degrees Fahrenheit, Tylenol was given. The patient's parents both tested positive for coronovirus disease 2019 (COVID-19) on the day prior. The patient was placed on phenobarbital until "sometime in the beginning of this year when the medication was discontinued" per her mother. 

The mother denied that the patient had chills, nausea, vomiting, rash, decreased by mouth (PO) intake, respiratory distress, recent travel, congestion, rhinorrhea or changes in appetite. The patient was brought by ambulance to the emergency room (ER). In the ER, the physical exam revealed a blood pressure (BP) of 106/65, heart rate (HR) 135, T 98.5 degrees, respiratory rate (RR) 26, and oxygen saturation (O2 sat) 97% on room air (RA). 

The patient was described as active and in no acute distress. The exam had no significant findings. The patient was admitted to the pediatric floor for "breakthrough seizure and exposure to COVID-19". She was not in respiratory distress, had no seizure activity in the ER. Lab results were unremarkable apart from COVID-19 positive. Upon admission to the floor, the patient was placed on seizure and fall precautions with Ativan as needed (PRN) for active seizure and Tylenol/Motrin as needed (PRN) for fever. Due to the COVID positive result, the patient was placed on contact and droplet isolation. As per the pediatric neurologist, an electroencephalogram (EEG) was recommended. The study returned abnormal. A recommendation was then made for a magnetic resonance imaging (MRI) scan of the brain without contrast to rule out an intracranial lesion and start Keppra 10 milligrams per kilogram (mg/kg)/dose twice daily (BID). The MRI scan of the brain was done and was read as unremarkable. There was no recurrence of a seizure throughout the hospital stay and no Ativan was given. The patient spiked 2 fevers (101.3 degrees, 101.5 degrees) on the second day of admission which resolved with Tylenol/ibuprofen. On the day of discharge, she was afebrile greater than (>) 24 hours. The patient otherwise was well with no complaints. Feeding was as per baseline with adequate urine and stool output. The parents were instructed to follow up with the neurologist and primary medical doctor (PMD) upon discharge. The patient was sent home on Keppra 10mg/kg/dose BID to continue until seen as outpatient. 
At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary for this patient. Although there are pediatric patients that may require inpatient hospitalization after presenting with a seizure, this patient did not meet criteria for inpatient status. At the time she was admitted to the hospital, there was never any mention of altered mental status, she did not have any neurological deficits, she was not toxic appearing, there was no mention of meningeal signs and no intractable vomiting. Her vital signs were stable and lab results were unremarkable except for her being COVID-19 positive. The patient was admitted with a plan for an EEG and pediatric neurology consultation. Both could have been done at a lower level of care with subsequent transition to outpatient care. For these reasons, an inpatient stay was not medically necessary. Patients that require hospitalization include those with neurological deficits, toxic appearance, meningeal signs, intractable vomiting, severe headache or altered mental status.