Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is overturned. 

This is a female who was admitted. The patient had a history of febrile seizures, speech delay and right occipital lobe epilepsy. The initial diagnosis of epilepsy was made and the patient was started on Keppra. The patient had an ambulatory electroencephalogram (EEG) which showed more than 50 seizures during the recording over 24 hours. The patient's Keppra was increased, and a video EEG was recommended to evaluate the seizures further. Since seizures continued, the patient's Keppra was increased further and the family was asked to bring the patient in for further evaluation to the Emergency Department (ED). The patient was thus brought to the ED. On the day of presentation to the ED, the patient had 6 clinical seizures reported by the family (staring in space/gaze deviation, stiffening of the extremities), each seizure lasting about 2 minutes. The patient was admitted for further management of her seizures as well as for a video EEG.
The patient underwent a video EEG evaluation. The patient was started on Vimpat during the hospitalization. On the first night of the study, the patient had 3 seizures captured and Vimpat was increased. The seizures were noted to be subclinical or with subtle clinical changes (arousal from sleep). The EEG monitoring was continued, during which one more seizure was captured but the seizure burden overall improved significantly.

At issue is the medical necessity of Inpatient Stay.
The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
Status epilepticus is an epilepsy emergency with a clear time-dependent relationship to morbidity and risk of mortality. However, status epilepticus is not a single entity; it has a number of different forms and a vast array of etiologies. The most unambiguous example of status epilepticus is convulsive status epilepticus. And then there are some less clear-cut forms, with repetitive seizures and nonconvulsive status epilepticus. Acute repetitive seizures/seizure clusters may be used to describe convulsive or nonconvulsive seizures. These are emergencies that present with acute episodes of consecutive seizures occurring within a short period, with the patient returning to a normal state during the inter-ictal period.
Despite lack of standardized nomenclature and definition, the epilepsy field generally considers seizure clusters a potential emergency that may benefit from treatment. Patients with seizure clusters are at risk for brain/neuronal damage, postictal psychosis, status epilepticus, and higher mortality relative to patients without clusters. Untreated seizure clusters may result in greater resistance to future drug treatment and lead to patient injury or status epilepticus. While there is no standard definition of "very frequent seizures", this patient had greater than (>) 50 seizures documented in a recent ambulatory EEG and at least 6 clinical seizures on the day of admission. This is an appropriate reason to evaluate the patient further for delineation of seizure types as well as for use of intravenous drugs for seizure management. This patient required inpatient evaluation with a continuous EEG monitoring as well as administration of IV (intravenous) medications for treatment of the patient's seizures.
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.