Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with history of depression, migraines, epilepsy, and memory impairment. She presented to the emergency department due to having two witnessed breakthrough seizures at home while in bed. She also had a seizure on the way to the hospital while in the ambulance. EMS (emergency medical services) treated the patient with Versed with resolution of the seizure event.

While in the emergency department, the patient was asleep but arousable, and she was noted to be in mild distress. It was noted she appeared to be possibly post-ictal, in that she was unable to name her neurologist and appeared to be slightly confused. She progressively became more alert and eventually was fully oriented. No other seizure activity was noted while in the emergency room.

CT (computed tomography) scan of the patient's head showed no acute intracranial pathology. Her antiepileptic medications were found to be sub-therapeutic. It was felt the patient had some medication non-compliance due to confusion about her dosages. Lab work was also positive for benzodiazepines, and urinalysis was positive. The patient had no memory of her seizures.

She was given Tylenol and IV (intravenous) fluids in the emergency room. It was noted she had been admitted week the prior with the same presentation and low Tegretol levels. Due to her breakthrough seizures and sub-therapeutic medication levels, the patient was admitted for further management.

The patient's antiepileptic medications were continued, including levetiracetam, lamotrigine, and carbamazepine. Levaquin was also administered due to possible urinary tract infection. The patient was monitored for her response to the medication. She was discharged after being found to be stable. Assistance with medication management was recommended.

No, the Inpatient admission was not medically necessary.
Medically necessary services are those that are provided for the diagnosis, treatment, cure, or relief of a health condition and are necessary and appropriate to the diagnosis, cure, or relief from a health condition. Medically necessary services must be within the generally accepted standards of medical care and not administered solely for the convenience of the patient or provider.

In the patient's case, breakthrough seizures were diagnosed and treated with Versed and was increased of the dose of the patient's medications. After the patient receive Versed, seizures stopped and she did not have any additional seizures. The patient's confusion gradually resolved. Therefore, acute inpatient admission was not appropriate for her diagnosis and was not in keeping with generally accepted standards of medical care. Medical literature (1) does not recommend that acute hospital admission is the main modality for treating breakthrough seizures. Therefore, the proposed treatment was not medically necessary or appropriate for the patient's diagnosis and health condition.

The patient had breakthrough seizures, which stopped. The patient was neurologically stable and regaining her level of alertness. Antiepileptic medications were administered. The patient was clinically stable. Therefore, inpatient admission was not medically necessary, and the patient could have been managed at a lower level of care.