Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Seizure
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient has no significant past medical history. She presented to the emergency department (ED) following a possible seizure or syncopal event at home. The patient was at home that evening and felt a tingling sensation in her hands and feet. Her hands and feet began to contract, and she lost consciousness. She noted hitting her head while getting into a boat one week prior. She did not seek medical attention. The patient endorsed central chest tightness and a headache. The patient was awake and oriented times (x) 3.  An electrocardiogram (EKG) showed normal sinus rhythm and no ischemic changes. Initial labs were unremarkable aside from elevated liver function test (LFTs). A computed tomography (CT) scan of the brain and spine were negative. She was admitted for workup of syncope versus seizure in the setting of recent head trauma. She was ordered for intravenous (IV) Keppra and as needed (PRN) Ativan. The plan was to consult Neurology. The Neurologist's physical exam was unremarkable. He wrote that he doubted the patient had a seizure given her description and recollection of the entire event. He wrote that her head injury and the patient being under stress may have contributed to her symptoms. He recommended a magnetic resonance imaging (MRI) scan of the brain and an electroencephalogram (EEG). The MRI of the brain returned with no significant findings.  Her LFTs were trending down, and her blood pressure was improved. A right upper quadrant (RUQ) ultrasound showed hepatomegaly and steatosis. Alcohol counseling was provided for alcohol use disorder. EEG  was negative.

Hospitalization at the inpatient level of care was not medically necessary for this patient. Admission at a lower level of care was more appropriate in this case. The patient did not meet Milliman Care Guidelines (MCG) criteria for inpatient admission for seizures. She was not hemodynamically unstable, was not felt to have had status epilepticus or repetitive seizures not controlled with emergent treatment and did not have a brain disorder that required monitoring available only at the inpatient level of care. She did not have a cardiac arrhythmia of immediate concern. She did not have altered mental status that was severe or persistent: she was awake, alert, and oriented x 3 on all exams. All of her Neurologic physical examinations were normal. Her vital signs were normal aside from mildly elevated blood pressure. The Neurologist attributed her symptoms to stress and prior head trauma. Workup including a CT head and MRI brain, which were both unremarkable, negative for either stroke or intracranial bleed. She had no metabolic abnormalities on blood work that would explain her symptoms.

The patient met MCG criteria for a lower level of care since her possible seizure episode put her beyond the scope of usual emergency department care and her stay should have been expected to last no more than two midnights. This patient required admission for further workup with an MRI and EEG. The Neurologist was doubtful that the patient had experienced a seizure given her description and recollection of the entire event. There was no indication for her to remain in hospital beyond lower-level length of care. Generally, patients with a first unprovoked seizure who have returned to their clinical baseline and have normal initial studies can be discharged from the ED with close outpatient follow up. Decisions may be individualized, however, and in this case given her recent history of head trauma it was prudent to admit her to the hospital for further workup, including an MRI and EEG. However, this could have been done under a lower level of care.