Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Staring Episodes.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

The medical records indicate the patient has staring spells and shaking fits during sleep, concerning for seizures. The patient was admitted to the hospital band completed a video electroencephalogram (vEEG) that was negative. 

According to the patient's discharge summary, the patient had their first seizure with shaking and stiffening "of the extremities lasting about 3-4 minutes each." The patient had no nursing issues, nor did they require any medication changes during this hospital stay. Lab values and vital signs were within normal limits; also, the electroencephalogram (EEG) was normal. 

The patient had no seizure activity during the stay in the hospital, and the patient was then discharged.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  
    
Admission to perform the vEEG was not appropriate for this patient.

The patient presented with complaints of seizure activity that were said to be staring without speaking and shaking during sleep. The patient was admitted, during which time they had a video electroencephalogram (vEEG) that was normal, all normal vital signs, laboratory values that were within normal limits and no seizure activity. 

As such, there were no data submitted or current medical literature to support that the admission for the performance of the vEEG was medically appropriate, as there was no indication that the medication needed to be withdrawn, no necessity for peri-ictal testing, no localization was needed for surgery and the patient was not being evaluated for nonepileptic seizures.

"After video-electroencephalography monitoring (VEM), the clinical diagnosis of patients can change, and unnecessary drug administration may be prevented. Psychogenic nonepileptic seizures and nonepileptic paroxysmal events (NEPEs) are common in the pediatric population; however, they are often overlooked" (Aslan, M., & Gungor, S. 2022).

"Long-term video-EEG monitoring has been the gold standard for diagnosis of epileptic and nonepileptic events. Medication changes, safety, and a lack of recording EEG in one's habitual environment may interfere with diagnostic representation and subsequently affect management. Some spells defy standard EEG because of ultradian and circadian times of occurrence, manifest nocturnal expression of epileptiform activity, and require classification for clarifying diagnostic input to identify optimal treatment. Some patients may be unaware of seizures, have frequent events, or subclinical seizures that require quantification before optimal management. The influence on antiseizure drug management and clinical drug research can be enlightened by long-term outpatient ambulatory EEG monitoring. With recent governmental shifts to focus on mobile health, ambulatory EEG monitoring has grown beyond diagnostic capabilities to target the dynamic effects of medical and nonmedical treatment for patients with epilepsy in their natural environment. Furthermore, newer applications in ambulatory monitoring include additional physiologic parameters (e.g., sleep, detection of myogenic signals, etc.) and extend treatment relevance to patients beyond seizure reduction alone addressing comorbid conditions. It is with this focus in mind that we direct our discussion on the present and future aspects of using ambulatory EEG monitoring in the treatment of patients with epilepsy" (Hasan, T. F., & Tatum, W. O., 4th 2021).                                                         

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 admission is not substantiated.