Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Nonresponsive; seizure. 

Treatment:  Inpatient admission.

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

This is an adult female, who was seen at the emergency department with a history of partial seizures, major depressive disorder with psychotic features, and left adrenal adenoma. It was reported that the patient was found blankly staring and not responsive, with a left gaze deviation after repeating words and then singing a song. The patient was noted to be aphasic and was not following commands. The Stroke code was activated upon triage, and there was noted suspicion of partial seizure. On examination, the patient was staring, aphasic, and moving all extremities, with normal heart and breath sounds on auscultation. It was noted that the patient had a generalized tonic-clonic seizure with left gaze deviation, full body shaking, foaming at the mouth, and urinary incontinence. The patient was administered Ativan intravenously (IV). The treatment plan included computed tomography (CT) of the head, lab work, video electroencephalogram (vEEG). On neurology assessment, the patient was drowsy and fell asleep throughout the exam. CT of the head noted no acute intracranial abnormality. Magnetic resonance imaging (MRI) noted mild chronic microvascular disease. Ceribell (EEG rapid response system) noted abnormal rapid montage EEG. It was stated that the patient was intermittently disoriented and in a post-ictal state, requiring admission. On day two, the patient was drowsy and in no acute distress. The patient demonstrated appropriate vocabulary and had normal motor strength and sensation in bilateral upper extremities, as well as cranial nerves intact. It was noted that the patient may have had a seizure due to possibly missing an at-home dose of Depakote. 

It was noted that the patient was treated actively for grand mal seizure and required intravenous benzodiazepine, as well as subtherapeutic levels of Depakote with improvement. 

Milliman Care Guidelines (MCG) states inpatient admission for seizure is indicated for 1 or more of the following: altered mental status that is severe or persistent, new focal neurological deficit, and/or metabolic disorder. The goal length of inpatient stay for seizure is noted to be 2 days, with care possibly including diagnostic testing, antiepileptic drugs, cardiac monitoring and pulse oximetry, consultation, and/or patient education. Evidence based literature indicates seizures are a common presentation at emergency departments, and this is often where initial management of seizure emergencies occurs. Additional literature indicates appropriate assessment and treatment of breakthrough seizures is crucial. The patient presented to the emergency department with aphasia, inability to follow commands, blank staring, acidosis, and eventual tonic-clonic seizure during evaluation. The patient was provided intravenous (IV) medication with improvement but continued to have an altered mental status and was unable to be safely discharged without further assessment and treatment. The patient was discharged the following day after she was determined to be stable and safe for discharge. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission is substantiated.