Appeal type: Medical necessity
Decision: Upheld

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

This patient reportedly was admitted to the hospital after having a tonic clonic seizure for the first time. He reportedly was shaking, had loss of consciousness, had postictal confusion, and bit his tongue. He reportedly was given Keppra and put on Ativan 2 mg (milligrams) IV (intravenous) if needed. He reportedly had an EKG (electrocardiogram) and neurology recommended an EEG (electroencephalogram). It was reported that the EKG was normal sinus rhythm with QT (interval on an ECG) interval changes. He reportedly was living with his family. He had no prior seizure history. 

The decision to deny coverage for an inpatient hospital treatment is supported as the medical records did not provide enough specific evidence supporting that he only required 24-hour acute medical hospital treatment then. The APA (American Psychiatric Association) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of an inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment , if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case it was not reported that this patient had an alcohol withdrawal or benzodiazepine withdrawal seizure as it was reported that he drank alcohol 1-2 drinks per month. Also, there were no reports that the seizure was caused by cannabis intoxication or withdrawal, and it was reported that he last used marijuana 1 week prior to the admission. It was reported that he had been ill from food poisoning one week prior to admission and had his first COVID vaccine. There were no reports of acute medical instability requiring only acute medical hospital treatment. He reportedly had a seizure and was postictal and was given Keppra but there was no specific evidence in the medical records supporting that he could not have been treated in the ED (emergency department) or observational setting. As a result, the recommendation is to uphold the previous decision and deny coverage for the inpatient hospital treatment. It appeared that the insurer acted reasonably and with good clinical judgment.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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