Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This case involves an infant, who presented to the emergency room (ER) with reports of first-time simple febrile convulsion, tonic-clonic, of 8-minute duration. According to the patient's mother, the patient was febrile the night before, and was warm to the touch. The mother noted the infant shaking and the eyes rolling upwards and stated that the episode lasted around 8-12 minutes. The shaking ceased after reaching the emergency department. The infant was lethargic and limp afterwards. The mother stated that the patient had not been eating solid foods as usual for the last day but was nursing appropriately. Initial vital signs recorded a temperature of 104.5 degrees Fahrenheit (F), a pulse of 159, respirations 33, and a pulse oximetry at 98% on room air. The Electroencephalography (EEG) was normal with the impression indicating new onset prolonged convulsive seizure with fever, possible complex febrile seizure. Recommendations included video EEG to evaluate for epileptic activity, pediatric neurology consultation, benzodiazepines as needed for seizures, with the patient given acetaminophen 120 milligrams (mg), lorazepam 0.4 mg Intravenously (IV), and Motrin suspension, should the patient have a fever greater than 100.4 degrees (F) Fahrenheit. The physician also ordered baseline liver function testing and subsequently admitted the patient.

According to the Milliman Care Guidelines, the patient did not meet the criteria for admission to inpatient care for pediatric seizure. The patient's care could have been administered on an outpatient or observational basis based upon the provided information. The patient was not found to be hemodynamically unstable given that favorable response to pharmacological measures and did not have focal seizure activity noted on the EEG, did not have prolonged seizure of 15 minutes or more, did not have more than 1 seizure within 24 hours, and there was no suspicion for meningitis. The patient was not status epilepticus, did not have a brain disorder requiring monitoring or intervention available only at inpatient level of care, nor was there an etiology that required monitoring or intervention available only at an inpatient level of care or that persisted despite observation care. The patient did not have evidence of altered mental status that was severe or persistent, had no new focal neurologic deficit procedure, and no metabolic disorder that persisted despite observation care. Lastly, there were no recurrent seizures, the patient did not require an outpatient antiepileptic regimen that could not have been established, and there was no cerebral bleeding, hydrocephalus, or vasospasm monitoring indicated. There was not a need for increased intracranial pressure or cerebral edema monitoring. The inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.