Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the hospital for evaluation of altered mental status and loss of consciousness concerning for seizure or syncope.  The patient had a history of seizures.  The patient described an aura sensation and believed that they had seizures the previous day and today.  The patient described racing heart and then waking up on the ground.  It was unclear if the patient had focal or generalized seizures in the past.  The patient was on Fycompa and Briviact and was adherent with the medications.  The patient reported that they would typically get aura sensation prior to seizure around the time of their period.  The patient reported that they felt that they were about to get their period.  The patient stated that they felt that they had a third episode with emergency medical services.  It was indicated that the patient nodded their head and there was no generalized tonic-clonic activity.  The patient's neurologist was called.  The provider stated that the patient has suspected psychogenic seizures, but the patient had been discharged from their clinic as the patient was no longer following the recommendations.  The patient was given the current medications but advised to find a new provider.  The patient had continuous electroencephalogram for 3 days and had some events that were captured on video but not associated with any electrographic seizure activity.  The patient had a history of real epilepsy in the past, but it was now suspected to be more psychogenic.  There were episodes in the past in which the patient stated that they could not walk but demonstrated full strength on exam.  While in the emergency department, the patient had an episode of possible seizure that lasted less than 1 minute and broke spontaneously.  Ativan was given prophylactically after the seizure broke.  The patient had turning of the head to the right, tense body, and was not responsive.  There was slight jerking of the leg but no overt tonic-clonic jerking motion.  There was slight right gaze deviation during the episode.  After the episode, the patient was awake and talking but had some twitching around the eye which resolved in less than 1 minute.  There was consideration for admission for syncope versus seizure.  Vital signs noted temperature of 98.7 Fahrenheit, heart rate of 108, and blood pressure 106/68.  Laboratory testing noted elevated troponin of 12.2.  Electrocardiogram demonstrated normal sinus rhythm.  Computed tomography (CT) of the head was unremarkable.  The urine drug screen was negative.  The patient was treated with intravenous (IV) fluid, Keppra, and Ativan.  

However, the documentation did not detail that there was hemodynamic instability that was not readily corrected by appropriate treatment, status epilepticus, that there was a brain disorder such as tumor, edema, trauma, or encephalitis that required monitoring or intervention available only at inpatient level of care, that the etiology was related to factors such as drug toxicity, withdrawal, or nonadherence that required monitoring or intervention available only at inpatient level of care, that there was altered mental status that was severe or persistent, that there was new focal neurologic deficit, that there was a metabolic disorder that persisted despite observation care, that there was recurrent seizure without known seizure disorder, that the seizure was a different seizure type than previously known, or that there was baseline of infrequent seizure and the recurrence was not thought to be due to readily modifiable etiology.  

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 an inpatient admission is not substantiated.