Appeal type: Medical necessity
Decision: Upheld

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

This case involves an adult with a past medical history significant for a seizure disorder, alcohol abuse, and psoriasis who presented to the emergency department with an unwitnessed seizure.  The patient was noncompliant with a prescription for Keppra.  Records state the patient presented to the emergency department with nausea, vomiting, and shakiness due to alcohol withdrawal.  The patient was admitted for further work-up and care.  A computed tomography (CT) of the head noted mild atrophy but no acute intracranial process.  Urine toxicology was negative, and neurology was consulted whereupon Keppra 500mg (milligram) to be taken orally twice a day was recommended.  For the patient's alcohol abuse disorder, he was managed with Ativan tapering dose.  The patient had multiple psoriatic rashes present in the lower body, face, neck, abdomen, back, and upper and lower extremities.  He had a mild tremor with his hand extended.  His listed diagnoses included seizures, seizure disorder, alcohol withdrawal syndrome without complication, vitamin D insufficiency, tremors of nervous system, and alcohol withdrawal seizure.  The report stated that the patient had an unwitnessed seizure episode while at a shelter.  At the time of admission, the patient was alert and oriented x (times) 4 (to person, place, time and event), ambulatory, and was given intravenous (IV) solution and remained nothing by mouth (NPO).  

During his stay, the patient was treated for his seizure disorder, alcohol withdrawal, and psoriasis.  The records stated the patient lives in a shelter with chronic alcohol use and medication noncompliance.  He claimed to have been lying in bed when he began shaking throughout his whole body.  He did not lose consciousness with no urinary or bowel incontinence.  He claimed that the shaking episode ended after around 15 minutes.  He claimed to have 1 episode of vomiting afterwards.  He was previously admitted with a complaint of seizure after trying to cut off alcohol.  The hospital notes stated the patient was alert and oriented x3 (to person, place and time) and would be admitted to stepdown for seizures and due to alcohol.  The report stated the patient refused inpatient treatment for alcohol abuse.  He was subsequently discharged.  

According to the Milliman Care Guidelines (MCG), inpatient care may be indicated for those individuals who have had a seizure due to drug toxicity, withdrawal, or nonadherence that requires monitoring or intervention available only at inpatient level of care or that persist despite observation care.  Those patients with alcohol withdrawal symptoms may be indicated for admission but the care cannot be managed at a lower level of treatment.  

The information provided for the review did not support that the patient met the criteria for inpatient admission.  While it was noted that he had a history of seizures and was noncompliant with the use of Keppra and had a known alcohol abuse disorder with reports of withdrawal symptoms, the evidence did suggest that his care could have been rendered safely and effectively on observational basis.  Based upon the provided documentation, the evidence did not support the need for inpatient care.  The patient displayed no further episodes of seizures and his other symptoms of nausea, vomiting, and shakiness due to alcohol withdrawal resolved with treatment.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient stay is not substantiated.