Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Seizures. 
Treatment: Inpatient admission. 
The health plan denied: Inpatient admission. 
The determination is: Overturned in part. 

The patient was brought to the emergency department (ED) with a seizure. At the time he had a febrile illness. He had vomited once, and other members of the family had a gastrointestinal illness. The grandmother who brought him to the ED said the mother had a febrile seizure as a child. At triage, he appeared well. Other than a temperature of 102.5 oF (degrees Fahrenheit), his vital signs were normal. The seizure was a staring episode (an "absence stare") without shaking of arms or legs that lasted about 30 seconds with color change to the lips. He then had a post-ictal drowsy period for 6-8 minutes. He had a fever at the time, and the febrile illness began the day before. He had vomited once and been treated with Tylenol for the fever. His exam was entirely normal. He was observed in the emergency room and given Tylenol; he continued to appear well and then was admitted to the pediatric ward. His temperature was down to 99.2 oF; he continued to appear well, and his exam was normal. It was noted that the maternal grandfather had a seizure in childhood (unspecified as to whether febrile or not) and then "grand mal epilepsy" in adulthood for which he received anti-epileptics. The pediatric ward assessment was "first episode of absence seizure with fever in setting of strong family history of seizures." 
During the hospitalization, he continued to spike fevers but continued to appear well and feed normally and not have any episodes of concern. Video electroencephalogram (EEG) was normal. Electrocardiography was normal. He was discharged home. 
At issue is the medical necessity of the inpatient admission. 
The health plan's determination of medical necessity is overturned in part. 
The requested health service/treatment of inpatient admission is partially medically necessary for this patient. 
The patient was brought to the emergency room with a staring spell and color change in the lips lasting 30 seconds followed by a drowsy period lasting a number of minutes. He had a fever at the time. Thereafter, he was completely normal-on arrival to the ED, after admission to the hospital, and during the entire hospitalization-except for spiking some fevers. He fed well and behaved normally. The screening laboratories and radiographs for metabolic problems, infection, and sepsis done in the emergency room were normal/negative. It appears he was admitted to expedite a neurological and cardiac workup for the event the grandmother described. The concern was with the color change to the lips, suggesting hypoxemia that could have been caused by a seizure (with apnea) or an arrhythmia. This patient did not have a typical febrile seizure, which is a generalized, clonic-tonic seizure with fever. Patients who are well after a clear febrile seizure do not require hospitalization. This patient did not have a typical absence seizure either-he was much younger than the usual age at onset, and the hallmark of absence seizures is multiple, brief staring episodes without a post-ictal period or color change. He reportedly had a 30 second staring episode with color change, and at the time he had a fever, which made him an unusual presentation. 
Given the concern for possible apnea, late evening extending to early morning, and the unusual presentation, perhaps the best unifying clinical diagnosis was Brief Resolved Unexplained Event (BRUE). It was reasonable to admit to the hospital to observe for life threatening events, intervene if necessary, and do a preliminary workup. 
After a period of observation and screening tests during the day, however, consisting of continued normal behavior, normal feeding, lack of any concerning events, a normal EKG (electrocardiogram) and normal EEG, the patient should have been discharged home. No more than one inpatient hospital day was medically necessary.