CLINICAL SUMMARY:
A six-year-old male patient with Lennox-Gastaut syndrome, a complex, rare and severe childhood-onset epilepsy, arrived in the emergency department (ED) after experiencing breakthrough cluster seizures at home and en route to the hospital after starting a new treatment medication the day prior. Once in the ED, the patient experienced three more seizures, one of which lasted three minutes. The patient’s seizures were difficult to control and ranged from general tonic-clonic to myoclonic with eye deviation.
Initially, the ED team evaluated the patient and decided upon discharge with a refill of Diastat and a plan to start a clonazepam bridge treatment at home. However, before leaving the ED, the patient experienced another seizure which caused a fall, preventing the patient from physically leaving the ED. The seizures continued in the ED despite being given 10mg of intranasal Versed, and the ED physician discussed the case with a pediatric neurologist at the university hospital where the patient was usually treated. A 1500mg IV dose of Keppra was recommended while the patient was monitored for another two hours in the ED.
The patient was then admitted to the pediatric hospitalist’s care for further monitoring. Following admission, another 60-second seizure occurred, but did not require abortive medication. Anti-epileptic medication continued to be administered throughout the night without additional seizures for the remainder of the patient’s stay. The patient was discharged the next day with a treatment plan developed in conjunction with the university pediatric neurologist, who would continue ongoing care.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe commercial insurance plan denied the one-day short stay inpatient admission, stating that medical services received did not meet the health plan rules. It was also stated that the child’s blood pressure and pulse rate were normal. Vital signs upon admission were as follows:
- Heart Rate: 86-120 (pediatric patient: 120 x 1, child was playing)
- Respiratory Rate: 19-30 (pediatric patient: >25 x 5)
- Blood Pressure: 103/71-132/80 (pediatric patient: SBP >110 x3, DBP >75 x 1)
The denial also indicated that the medical record notes did not reflect a new type of seizure and that the patient’s seizures were controlled. The decision to deny coverage was based upon the MCG guidelines for pediatric seizures.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAn AppriseMD physician advisor completed a peer-to-peer discussion with the commercial insurance medical director regarding the one-day denial and was able to overturn this short stay by discussing the medical complexities involved. The AppriseMD physician advisor reviewed the patient’s history, including the multiple breakthrough seizures associated with Lennox-Gastaut syndrome, treatment which required IV Keppra and a consult with a pediatric neurologist. Further, the active seizure activity indicating high risk after presentation to the hospital demonstrated that inpatient level of care was appropriate, and the carrier reversed course and approved the inpatient admission.