Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

This case involves a female with a history of Moyamoya disease with residual left hemiparesis, Pontine infarct, asthma, depression, and a seizure disorder with noncompliance. She was diagnosed with childhood epilepsy at the age of 3. The patient reported that she did not take her medication regularly. She was known to neurology and had a recent increase in Keppra for breakthrough seizures. The provider was unable to obtain review of systems due to mental status change.  The vital signs at triage noted blood pressure 146/85, temperature of 98.5 F (farenheit), pulse of 113, respiratory rate of 18. The exam findings noted that the patient was listless, arousing to a sternal rub, status post Ativan. She was moving all extremities and her pupils were equal and reactive bilaterally to light and accommodation. There were no signs of trauma. The provider noted that the seizures were likely secondary to medication noncompliance. However, less likely possible causes included metabolic/endocrine or electrolyte abnormality, infectious process, breakthrough seizures, tumor, intracranial process, metabolic encephalopathy secondary to uremia, and alcohol or drug intoxication. 

Per the MCG (Milliman Care Guidelines), admission to the hospital for seizures is recommended when there is hemodynamic instability, status epilepticus, etiology including nonadherence that requires monitoring or intervention available only at inpatient level of care or that persist despite observation care, altered mental status that is severe or persistent such as with lethargy that persists more than a few hours despite appropriate treatment, metabolic disorder that persists despite observation care, or for recurrent seizures that are different seizure types and previously known seizure disorder. In this case, the patient presented to the hospital with reports of multiple seizures. She reported noncompliance with medications as it made her sleepy. On exam, she was reported to have a mental status change. She was listless. It was also noted that she received Valium by emergency medical services and then Ativan to address seizure-like activity. While in the emergency department she had 1 episode of seizure-like activity which resolved with minimal to no postictal period. It was argued that the patient met criteria for an inpatient admission. The medical emergency services were concerned that the patient may be in a status of epilepticus. The patient had acute mental status change. The patient was noted to be tachycardic on exam.  There were reports of dizziness and sleepiness. There were abnormal laboratory findings. The patient required continuous monitoring of vital signs. Her care could not have been provided in the outpatient setting. However, the documentation did not reveal hemodynamic instability, findings of status epilepticus, or symptoms of altered mental status and requirements of monitoring or intervention that persisted despite observation care. The documentation did not reveal that the patient's seizures were a different type of seizure than previously known. As such, the patient's care could have been completed in an observation setting. Therefore, the healthcare plan acted reasonably with sound medical judgment and in the best interest of the patient.  

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.