Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epilepsy

Treatment:  for an elective inpatient admission for Video Electroencephalographic (VEEG) monitoring.

The insurer denied coverage for an elective inpatient admission for Video Electroencephalographic (VEEG) monitoring.

The denial is overturned.

The patient's past medical history includes asthma, chronic pulmonary heart disease, diabetes mellitus, depression, high cholesterol, lupus, and thyroid disorder. The patient presented to Neurologist office for  Electroencephalography (EEG) / Epilepsy, Clinical Neurophysiology, and further evaluation of episodes of loss of consciousness (LOC).

There was a magnetic resonance imaging (MRI) of the brain which showed resolution of the previously seen left frontal subdural collection. 

The doctor noted that the claimant had history of subdural hematoma and episodes of loss of consciousness. She noted that the claimant had psychiatric comorbidities. She noted that the 24 hours ambulatory electroencephalogram (EEG) showed frequent bursts of sharply contoured frontal predominant delta activity. She noted that the  Epilepsy Monitoring Unit (EMU) admission is necessary to differentiate epileptic from non epileptic events and to establish the specific type of epilepsy. She noted that outpatient 24-48 hours of outpatient recording will not allow enough time to record for the seizure-like events. 

The patient was seen by doctor for evaluation of episodes of loss of consciousness. She noted that the claimant had four episodes in the last year. She noted that the patient had an ambulatory Electroencephalography (EEG) which captured an episode of dizziness with no EEG correlate. She noted that the patient's son had epilepsy. She noted that the patient was on Lamictal. In the assessment she noted that the claimant spells were suggestive of vasovagal syncope but due to reported myoclonic jerks and the questionable interictal abnormalities seen on ambulatory EEG the plan was to admit to an epilepsy monitoring unit. 

There was a letter from the insurance stating the decision to deny coverage of EMU admission. The health care plan did not act reasonably and with sound medical judgment or in the best interest of the patient.

The best interest of the patient would be to have, in terms of diagnosis and ultimately treatment to have an EMU evaluation as the ambulatory EEG was not diagnostic.      

An elective inpatient admission for Video Electroencephalographic (VEEG) monitoring is considered medically necessary as the patient had seizure like events, with prior history of structural brain abnormality, and suspicious discharges on the ambulatory EEG. With the high risk of psychogenic non epileptic seizures there is a possibility that the patient would need a longer duration of recording than what a 24-48 outpatient EEG can offer. (1,3) 5 days of recording was the optimal time to record interictal discharges and first seizure which cannot be done with the ambulatory EEG. (2)

Per Friedman et al (2009), "Based on our results, it is common to require 3 or more days in an epilepsy monitoring unit to record and diagnose the nature of paroxysmal episodes and not rare to require more than a week. Interictal electroencephalography alone cannot reliably distinguish between those with epileptic seizures and nonepileptic events."

The insurer's denial of coverage for an elective inpatient admission for Video Electroencephalographic (VEEG) monitoring is reversed. Medical Necessity is substantiated.