Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure.

Treatment: Hospital admission.

The insurer denied coverage for hospital admission.

The denial is upheld.

This case involves a pre-adolescent patient with a history of juvenile myoclonic epilepsy and mild persistent asthma who was seen in the emergency department because of convulsive episodes that occurred at school. The patient stated the episodes lasted for approximately 2 minutes without a loss of consciousness. The patient described brief spasms throughout the body. The patient was previously seen for similar complaints. The patient was taking Keppra 7 milliliters (mL) twice a day and reported compliance with the medication. Laboratory values were normal with no abnormal findings on physical examination. The impression was of generalized epilepsy with a history suggestive of juvenile myoclonic epilepsy. The recommendation was to continue video electroencephalogram (EEG) monitoring overnight to try to record an actual event while on the patient's current Keppra doses. The patient was placed on seizure and fall precautions. The patient received a notice of adverse determination regarding the hospital admission stating that the video EEG was abnormal, but the patient's vital signs were stable with no documentation that the patient required or had not responded to treatment requiring care for more than 48 hours. It was determined that the patient's care could have been managed on an observational basis and admission was not medically necessary. An appeal was submitted stating that the patient required close monitoring with video electroencephalogram and required medication changes. The patient's care could not have been managed at a lower level of care due to the acuity on presentation. This review pertains to the denial of coverage for a hospital admission.

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care include those individuals who are hemodynamically unstable, have febrile seizures, or status epilepticus, had a brain disorder that requires monitoring or intervention available only at inpatient level of care, when there is etiology that requires monitoring or intervention available only at inpatient level of care or that persists despite observation care. It may also be indicated for altered mental status that is severe or persistent, when there is no focal neurologic deficit, a metabolic disorder, when there are recurrent seizures to include that the patient did not have a known seizure disorder, had recurrent seizures of a different seizure type than previously known seizure disorder, or was with a baseline of infrequent seizures with recurrence not thought to be due to readily modifiable etiology. Inpatient care may be indicated when outpatient antiepileptic regimen cannot be established, when monitoring is needed for cerebral bleeding, hydrocephalus, or vasospasm, and when monitoring is needed for increased intracranial pressure or cerebral edema. 

Based upon the provided documentation, the patient was hemodynamically stable, did not have febrile seizures, was not status epilepticus, did not have a brain disorder, and did not meet the additional criteria established by the Milliman Care Guidelines for inpatient treatment. When the patient arrived at the emergency department, the patient was no longer having seizures and while the patient reportedly had an abnormal EEG, the patient had a known seizure disorder, but did not require inpatient care to address the symptoms. The patient could have undergone close monitoring with video EEG and had medication changes while on observational status. The patient did not require acute care. The hospital admission was not medically necessary for this patient.

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.