Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blank staring, unresponsiveness.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a female infant referred to the emergency department to rule out absence seizures. The mother reported multiple episodes over the past three and a half months of gazing into the distance with no response for several seconds. She would not blink or respond to the mother's voice. There was no history of trauma or vomiting. The patient's vital signs were stabler. Examination was significant for no distress, no rashes, moist mucous membranes, clear lungs, no murmur, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was significant for mild thrombocytosis (412 thousand), white blood cell (WBC) count 10.1 thousand with 86% lymphocytes, unremarkable urinalysis, hyperkalemia (5.8), hyperphosphatemia (6.5), aspartate aminotransferase (AST) 39, creatine kinase 171, and alkaline phosphate 354. Urine toxicology was negative, and rapid viral screen was negative (respiratory syncytial virus [RSV], influenza, COVID19). The patient was admitted for seizure work-up with video electroencephalogram (EEG). On developmental screen at admission, the patient was rolling front to back, cooing, bringing hands to midline, grasps objects, orients to voice, explores hands and feet, and gets up on her hands when prone. Admission orders included electrocardiogram, video electroencephalogram monitoring, and Ativan as needed for seizure. The patient did well the first night with no adverse events. She was being monitored with video electroencephalogram. She remained on video electroencephalogram which remained inconclusive as of day two. Plans were made for magnetic resonance image (MRI) the following day with anesthesia. The non-contrast study was essentially unremarkable. The video electroencephalogram revealed the following: organized awake and asleep activities; mild intermittent focal slowing in the occipital region right greater than left; frequent low voltage epileptiform sharp waves in the occipital regions, bi-synchronously, but more prominent on the right side, occurring either isolated or in runs, again seen predominantly during wakefulness and drowsiness, less so during sleep; event reports not clearly associated with electrographic epileptic seizures; and similar electroencephalogram changes noted intermittently without clinical or behavioral changes reports. The interpretation was suggestive of focal cerebral dysfunction and/or structural abnormality in the occipital regions right greater than left with interictal epileptogenic cortical hyper-excitability with no actual or clear electrographic seizures seen. Further evaluation was recommended, including neurodevelopmental evaluation, neurometabolic evaluation, and genetic evaluation. The patient was deemed stable for discharge on day three to follow-up with the appropriate subspecialists.

The acute inpatient admission was not medically necessary.

This infant began having staring spells at a few weeks of life that was eventually brought to medical attention at a routine visit. The baby was referred to the emergency department for
admission for video electroencephalogram monitoring and possibility of imaging. She was monitored on video electroencephalogram from admission until the morning of her magnetic resonance image. The findings were relatively non-specific and were suggestive of focal cerebral dysfunction. Brain 
magnetic resonance image was unremarkable. The patient was discharged after diagnostic testing was completed to follow-up with multiple subspecialists. While it was medically appropriate to 
monitor with diagnostic testing, the patient was overall stable with no underlying medical problems, no evidence of overt seizures, and no evidence of status. She did not require acute inpatient admission and she could have been safely managed at a lower level of care.