Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had been diagnosed with focal epilepsy, attention deficit hyperactivity disorder and developmental delay. She was admitted to the hospital with the aim of capturing for differential diagnosis frequent events that were concerning for seizures of a different semiology from her typical seizures.
The patient's examination was significant for hyperactivity and poor attention. She had slight posturing of the right arm at times. Video electroencephalogram (EEG) telemetry did not capture episodes of concern, and there were no electrographic or electroclinical seizures. The recording was abnormal, with left temporal and frontotemporal spikes, and a right temporal spike.
At issue in this review is whether the requested health service/treatment of inpatient stay was medically necessary for this patient

The requested health service/treatment of inpatient stay was medically necessary for this patient. Inpatient video telemetry was medically necessary to capture for differential diagnosis events concerning for seizures, which were of a different semiology from her typical seizures. The patient was already taking an anticonvulsant medication.
She already has a history of attention deficit hyperactivity disorder and behavioral issues. Empirically adding a second anticonvulsant for the events concerning for seizures would place her at risk of additional behavioral problems.
If the events were seizures, the patient was at increased risk of SUDEP (Sudden Unexplained Death in a Patient with Epilepsy). She has several risk factors, including seizures occurring during sleep, and developmental delay. Video EEG telemetry for the differential diagnosis of the events concerning for seizures was medically necessary.
Nordli (1) describes that indications for video EEG telemetry in children include clarifying the nature of paroxysmal events, quantifying the frequency of seizures, and identifying the epilepsy syndrome. Ictal recordings can be obtained in children with refractory seizures who are being evaluated for the potential for epilepsy surgery. In a retrospective review of 1000 children with epilepsy who underwent video EEG telemetry, Asano et al (2) reported that "approximately half of the children with successful classification of epilepsy were assigned a specific diagnosis of epilepsy syndrome according to the International League Against Epilepsy (ILAE) classification." Alix et al (3) describe that useful clinical information is obtained in most children in whom events are captured on video EEG telemetry.
The patient has focal epilepsy with documented generalized tonic clonic seizures at night during sleep. This places her at higher risk for Sudden Unexpected Death in Epilepsy (SUDEP). Sudden unexpected death in epilepsy (SUDEP) affects about 1 in 1000 people with epilepsy.
Verducci et al (4) reviewed all cases of SUDEP referred to the North American SUDEP Registry (NASR) between October 2011 and June 2018. "The cause of death was determined by consensus review. Available medical records, death scene investigation reports, autopsy reports, and next-of-kin interviews were reviewed for all cases of SUDEP. Seizure type, electroencephalogram (EEG), magnetic resonance imaging (MRI), and SUDEP classification were adjudicated by 2 epileptologists.
There were 237 definite and probable cases of SUDEP among 530 NASR participants. SUDEP decedents had a median age of 26 (range 1-70) years at death, and 38% were female. In 143 with sufficient information, 40% had generalized and 60% had focal epilepsy. SUDEP affected the full spectrum of epilepsies, from benign epilepsy with centrotemporal spikes (number [n] equals [=] 3, 1 percent [%]) to intractable epileptic encephalopathies (n = 27, 11%). Most (93%) SUDEPs were unwitnessed; 70% occurred during apparent sleep; and 69% of patients were prone." The patient has an additional risk factor for SUDEP, as she is described as having a history of developmental delay Novak et al (5) found the presence of developmental intellectual disability may increase the risk of SUDEP through direct influence on decreasing the vagus nerve-mediated heart rate variability.