Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure disorder

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of cerebral palsy, developmental disability, and seizure disorder.

This case involves a female toddler who was taken to the Emergency Department (ED) due to jerking movements on the right side of her body with stiffening of the left leg. The documentation does indicate she has a history of cerebral palsy, as well as developmental disability and seizure disorder. The submitted documentation does not include the ED note; however, it is documented that the patient was admitted. The submitted documentation does detail the patient was brought to the hospital due to sudden jerking on the right side with stiffening of the left half of the body. The patient's father also endorsed associated upward rolling of eyes and frothing from mouth. The episode lasted 5 to 10 minutes and therefore Emergency Medical Services (EMS) were called. Upon arrival she was noted to have tonic-clonic movements. EMS did administer 3 mg (milligrams) of midazolam, which resolved the seizure. The patient's father indicated the patient was on Keppra up until a few months prior; however, he has not refilled her prescription. She was in no acute distress. She was noted to be tachycardic, otherwise her vital signs were within normal limits. She was having mild contractions moving her upper and lower extremities. She was back to baseline however, per her parents. Laboratory studies were performed and were pertinent for mildly decreased bicarbonate and mildly elevated aspartate aminotransferase (AST). She was started on intravenous (IV) Keppra and due to history of medication discontinuation and seizure, she was admitted for a neurology observation and medication reconciliation. Upon admission she was back to baseline and did not have any additional episodes. It was recommended she continue with Keppra, and nutrition was consulted for decreased oral intake. She remained hemodynamically and medically stable. The following day she was discharged given the lack of further adverse events.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe/persistent, or there is evidence of hemodynamic instability. The submitted documentation does not detail that the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient was back at her baseline and was discharged after 1 day. The requested inpatient admission would not be the most appropriate level of care and therefore, the prior denial remains upheld.

According to the guidelines, the acuity of this case is considered to have required observation as the patient with a known seizure disorder who presents with an uncomplicated seizure that was resolved prior to arrival. Upon arrival, the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the stay. Precautionary testing found mildly elevated muscle enzymes and mild acidosis. Keppra was provided and a nutrition consult provided for poor intake. The patient was described as interactive and at baseline upon discharge. The patient did not require an escalated level of care.

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.