Diagnosis: Seizures
Treatment: Inpatient Hospital
The health plan denied the inpatient stay.
The health plan's determination is overturned.

The patient is a male who presented to the emergency department after a staring episode.
He was well until approximately a month prior to presentation when he had his first episode of staring. The episodes occurred twice a day and lasted for a few seconds. He did not have any shaking or involuntary movements. He was seen by his primary doctor for his health supervision visit and had an episode of staring during the visit. He was subsequently referred to the emergency department for evaluation of these episodes. His past history was significant for premature birth. Upon presentation he had a temperature of 100 F. His physical examination was normal. Laboratory values were obtained, and he was admitted for evaluation of possible seizures.
He was admitted with seizure precautions and monitoring, with Ativan ordered as needed. A video electroencephalogram (EEG) was obtained as well as a consultation from the neurology team. He did not have staring episodes during the admission, and the video EEG did not show seizure activity. The neurology team also recommended a head magnetic resonance imaging (MRI), and he was given intravenous fluids in preparation for the study. The MRI was normal. He remained stable, he was felt to be stable for discharge to home with follow up as an outpatient.
The hospitalization is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service of the inpatient stay was medically necessary for this patient. This is a patient who presented with unexplained staring spells. He was referred to the emergency department after one of the events was observed in the primary care physician's office. He required prompt evaluation for possible seizures or other causes of paroxysmal behavior. His evaluation included video EEG monitoring, which needs to be done in an inpatient setting, as well as an MRI study, while monitoring for other possible etiologies and with administration of intravenous fluids in preparation for the study. While typical absence seizures cause staring episodes and are often benign, they typically present at an older age (mean age 6 years). Staring episodes in a can be a sign of a much more serious disorder, including seizures or sepsis, and require prompt evaluation with close monitoring for potential deterioration of clinical status.