Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure-Like Activity

Treatment inpatient emergency admission

The insurer denied coverage for inpatient emergency admission

The denial is upheld

This case involves a child who presented to the emergency room. The patient had a history of sickle cell anemia/beta thalassemia. She presented for evaluation of seizure-like activity. The episode lasted for 5 seconds, and the patient vomited after. The patient's mother reported witnessing the seizure-like episodes. Per the patient's mother, the patient's eyes rolled back, she became unsteady on her feet, her skin color turned gray, and the patient was turning unresponsive. An hour after the first witnessed episode, the patient was noted to have a second episode of her eyes rolling back with unsteadiness. The patient's parent reported a similar episode when the patient was sick with the flu. Testing was positive for rhino-enterovirus. The patient received 1 liter of intravenous normal saline bolus. An electroencephalogram was within normal limits. The patient was admitted to the floor in stable condition. Magnetic brain resonance imaging was recommended with sedation to rule out silent infarction. Anesthesiology was consulted. The patient was made nothing by mouth in preparation for the procedure. The magnetic resonance imaging with sedation required continuous monitoring by anesthesia. Magnetic resonance imaging of the head was negative. Electrocardiogram revealed sinus bradycardia with sinus arrhythmia. The assessment was documented as seizure-like episodes related to dehydration and illness versus a febrile seizure-like event. The patient was able to tolerate a regular diet and she was discharged home.

Per the referenced sources, admission for pediatric patients procedures is recommended in those with hemodynamic instability, when the etiology requires monitoring or intervention available only at the inpatient level of care, for those who have symptoms that persist despite observation care, those with bradycardia with syncope or ongoing dizziness, recurrent seizures as noted during the emergency department or observation care, and when patients have increased intracranial pressure or cerebral edema that requires monitoring. 

In this case, the patient presented to the hospital with reports of seizure-like activity. The patient had a history of sickle cell anemia/beta thalassemia. It was argued that the inpatient emergency admission was medically necessary. The patient was noted to have elevated transaminases, hyponatremia, and metabolic acidosis. The infectious work-up was positive for rhinovirus/enterovirus. Intravenous fluids were given for dehydration. There was a concern for febrile seizures. Neurology recommended admitting the patient. The provider noted that admission was indicated for etiology that required monitoring or intervention available only at the inpatient level of care in those with symptoms that persisted despite observation care and for recurrent seizures. 

The patient had no known seizure disorder and experienced recurrent witnessed seizures. Although it was reported that the patient had observed seizure-like activity by the parent, the documentation did not identify that any seizure-like activity was observed in the emergency department or during observation care. The documentation did not identify hemodynamic instability that was not readily corrected. The documentation did not identify syncope or ongoing dizziness. The documentation did not identify increased intracranial pressure or cerebral edema that would require monitoring. Thus, the patient was appropriate for observation care but not admission. 

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

The insurer's denial of coverage for an inpatient emergency admission is upheld. Medical necessity is not substantiated.