Appeal type: Medical necessity
Decision: Upheld

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

This case involves a young female patient who presented to the hospital for episode of unresponsiveness that lasted for approximately 25 to 30 minutes. The initial complaint was syncope. Video electroencephalogram (EEG) noted very rare, isolated single bursts of low voltage diffuse spikes noted during sleep and wakefulness. History was suggestive of seizures, not syncope. EEG was suggestive of generalized epilepsy but not yet conclusive. The patient was very sleepy at school. Her teacher sent her to the restroom to wash her face. The patient did not return for 10 to 15 minutes. She was found sleeping on the toilet. She was unresponsive to both verbal and tactile stimuli. Emergency medical services (EMS) were called. The patient regained consciousness after oxygen mask was applied. Upon awaking, she was not oriented to place. However, she could recognize her mother and principal. There was no family history of epilepsy. The assessment was episode of unresponsiveness for 25 to 30 minutes followed by postictal state. The patient was now back to baseline. There is consideration for toxic exposure, epilepsy syndrome, structural abnormality/space-occupying lesion, metabolic etiology, and psychosomatic/pseudoseizure. The patient had continued video EEG and was started on seizure precautions. A urine drug screen was negative. Laboratory testing including comprehensive metabolic panel (CMP) were unremarkable. Electrocardiogram was normal. Antiepileptic medications were not recommended. The patient was deemed stable for discharge.

In this case, the patient presented to the hospital due to an unresponsive episode. It was argued that the inpatient hospital admission was substantiated by the clinical documentation provided for review. The patient required close inpatient monitoring and timely work-up to evaluate for seizure activity and space-occupying lesions in the brain. This could not have been done in the outpatient setting. The patient could not have been managed at a lower level of care due to the acuity of altered mental status and unresponsiveness concerning for seizure activity. The patient had neurological abnormalities, severe electrolyte abnormalities, severe metabolic abnormality, and needed inpatient monitoring which included vital sign checks more frequently than every 4 hours and neurological checks more frequently than every 4 hours.  

However, the documentation did not detail hemodynamic instability that could not be corrected by appropriate treatment, the documentation did not detail severe persistent altered mental status, there was no evidence of cardiac disease or finding, the patient did not have dehydration that was severe persistent, the patient's episode did not cause injury that required hospitalization, the patient was not status epilepticus, the patient did not have evidence of brain disorder, there were no new focal neurological deficits, there was not a metabolic disorder that persisted despite observation care, there were no recurrent seizures, there was no increased intracranial pressure or cerebral edema, there was not a need for antiepileptic medication, and the patient did not require monitoring or intervention that was only available inpatient level of care. The patient's care, diagnostic work-up, and monitoring could have been completed at observation level of care. 

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 hospital admission is not substantiated.