Diagnosis: Seizure
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned.

The patient is a boy with a history of benign Rolandic epilepsy who presented with 2 back-to-back seizures. He was well until the day of presentation when he was sleeping and suddenly began to shake. He had tonic clonic movements of all 4 limbs and had urinary incontinence, frothing from his mouth, and his eyes rolled up. He was unresponsive during the episode, which lasted around 4 minutes. The emergency medical services team arrived and found him sleepy and unresponsive. In the ambulance he had a second seizure episode that involved his face. He was placed on an oxygen non-rebreather mask. The second seizure lasted for the whole ambulance ride which was approximately 10 minutes.

Inpatient hospital admission was medically necessary for this patient.

This is a young boy with a seizure disorder who presented with 2 back-to-back seizures. The second seizure lasted more than 10 minutes, and he had a prolonged post-ictal phase. Upon arrival to the emergency department, he was unresponsive and then vomited. He required inpatient admission for intravenous fluids, frequent neurology checks, and continuous monitoring with additional treatments as needed. He also required specialist consultation and an electroencephalogram (EEG).

The decision making at the time of admission for this patient was consistent with his young age, the occurrence of 2 back-to-back seizures, and the need for intensive monitoring and evaluation, intravenous fluids, and specialist care, which requires an inpatient setting.