Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for temporal lobe epilepsy who came to the emergency department after having a witnessed generalized seizure. The seizure lasted for five minutes. While in the emergency department, the patient had another seizure, which was aborted by the administration of Ativan. The patient was unaware of the seizure episode. Reportedly, the patient had several hospital admissions because of breakthrough seizures, which were attributed to medical noncompliance with antiepileptic medications regimen. When seen by the admitting physician the patient denied any recent illness, fever, chills, headache, dizziness, lightheadedness, chest pain, shortness of breath, abdominal pain, or any other symptoms.
On arrival at the emergency department, the patient was afebrile. The blood pressure was 142/78, heart rate 78 beats per minute (bpm), respiratory rate 20 breaths/minute, and oxygen saturation 99% on room air. When seen by the admitting physician, the patient appeared to be a well-developed, well-nourished individual who was resting comfortably, in no acute distress.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The neurological exam revealed no focal deficits. The patient was awake, alert, and oriented times three.
Laboratory evaluation revealed that the white blood cell count was 7.7, hemoglobin 13.2, hematocrit 36, and platelets 224. The sodium was 142, potassium 4.7, chloride 109, bicarbonate 15, blood urea nitrogen (BUN) 9, creatinine 0.88, and glucose 91.
A chest x-ray showed an increased density in the left retro cardiac region, which could reflect a small infiltrate. In the emergency department, the patient received treatment with intravenous Keppra.
The patient was admitted to the hospital with a diagnosis of seizures due to noncompliance with medications versus breakthrough seizures. She was continued on Keppra, Lamotrigine, Oxcarbazepine. The patient received treatment with intravenous fluids due to mild rhabdomyolysis.
According to the medical records, no additional seizure activity was seen during the entire hospital stay. The mild lactic acidosis and the rhabdomyolysis resolved after the administration of intravenous fluids. The CT (computerized tomography) scan of the head was unremarkable.
During the hospital stay, she remained in stable clinical condition and was discharged home. At issue is the medical necessity of an inpatient stay.


The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records demonstrated that at the time of admission and during the entire hospital stay the patient remained hemodynamically stable. There was no evidence that the patient had status epilepticus. The imaging studies did not reveal the presence of brain disorders such as tumor, edema, trauma, hydrocephalus.
There was no mention that the patient's seizures were associated with an infectious process such as encephalitis or meningitis. There was no evidence that the seizures were the result of drug toxicity or withdrawal. There was no mention that the patient had any cardiac arrhythmias of immediate concern.
The physical exam did not reveal new focal neurologic deficits. Laboratory evaluation was not consistent with metabolic abnormalities. It was indicated in the notes that during the entire hospital stay the patient remained seizure-free.
Furthermore, there was no mention that the patient had increased intracranial pressure or cerebral edema. Once, the patient received treatment with antiseizure medications in the emergency department, she had no recurrent seizures.
Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Care could have been provided at a lower level.