Diagnosis: Seizures
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of attention deficit hyperactivity disorder (ADHD) and global developmental delay of unknown etiology. She was in her usual state of health until she had a generalized tonic-clonic seizure, which stopped spontaneously. For evaluation of this seizure, she was taken to the emergency room, where she had a second documented generalized tonic-clonic seizure and for which she was treated with Ativan. In the emergency room, she was noted to have a fever of 101.5 degrees Fahrenheit (F). Because of the combination of recurrent seizures and fever, she was admitted at an acute level of care to the pediatric intensive care unit, where she was treated with antibiotics and an anticonvulsant. She also underwent continuous electroencephalogram (EEG) monitoring, which showed diffuse slowing, but no epileptiform activity. She was discharged from the hospital on Keppra and a 10-day course of antibiotics. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary. She had complex febrile seizures. The febrile seizures were considered complex because they were recurrent.
The patient had recurrent seizures and a documented fever. Whenever a child has a new onset of seizures in the context of a fever, they may have a serious neurological infection or they may have complex febrile seizures. In either case, admission to the hospital at an acute level of care is appropriate. It would not be appropriate to send a child home under these circumstances. To discharge a child to home under these circumstances would expose the child to the risk of having an untreated serious neurological infection, such as meningitis, or to having further, untreated recurrent febrile seizures. Instead, children with recurrent seizures in the presence of fever should be admitted and treated with anticonvulsants and antibiotics, as this patient was. According to the Milliman Care Guidelines for Pediatrics, inpatient admission to the hospital is indicated for complex febrile seizures, including recurrent febrile seizures.