Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with concerns of a seizure episode. Her pertinent medical history included seizure disorder. The initial vital signs revealed the patient to be afebrile and hemodynamically stable. The initial examination documented the patient as alert and oriented without focal neurologic deficits. The electrocardiogram (EKG) was unremarkable. The laboratory testing revealed a white blood cell count (WBC) of 7.6, hemoglobin 13.0, platelets (Plt) 330, blood urea nitrogen (BUN) 17, creatinine 0.8 and her glucose was 90. Her potential hydrogen (pH) was 7.36, carbon dioxide (CO2) 57, bicarbonate (HCO3) 31.5 and her troponin and alcohol were negative.

The chest x-ray (CXR) and the computed tomography (CT) of the head were unremarkable. Tylenol and intravenous fluids were provided. The patient was placed in the hospital thereafter with an impression of seizure likely related to medication-noncompliance. The treatment plan included neurological checks, a routine electroencephalogram (EEG), and a neurology consultation. Neurology was consulted who recommended a routine EEG, a magnetic resonance imaging (MRI) of the brain, and to not initiate an anti-epileptic drug at this time. Neurosurgery was consulted and did not recommend intervention of known pericallosal lipoma. The EEG was unremarkable. The patient was discharged.
  
The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

Based on the clinical documentation provided, evidence based literature and standards of care, the acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.

The American Academy of Family Physicians (AAFP) published guidelines regarding the evaluation and management of seizure, mainly first known episode. They note that the patient history and physical examination should focus on events directly preceding the seizure, the number of seizures in the past 24 hours, the length and description of the seizure, focal aspects (e.g., unilateral movements, eye deviation, head turning to one side), length of the postictal period, and the neurologic examination. This allows proper categorization as well as etiology identification and recurrence risk. Thereafter, in agreement with the American College of Emergency Physicians (ACEP), a computed tomography (CT) of the head with and without contrast should be performed to look for structural lesions. Both the AAFP as well as the ACEP note that stable patients who have returned to baseline neurologic status in the emergency department may be discharged and scheduled for outpatient neurology if follow-up can be ensured. Additionally, laboratory tests can be performed but should be tailored to the individual patient and driven primarily by findings from the history and examination (e.g., glucose level in a diabetic, liver function tests/ammonia in a cirrhotic).[1]

The patient had a history of seizure disorder and presented with witnessed seizures at home. On arrival, the patient was awake, alert, oriented, hemodynamically stable, and without focal neurologic deficits. An extensive evaluation including laboratory testing and head imaging was essentially unremarkable. Neurology was consulted and recommended additional diagnostic testing. The treatment plan included diagnostic testing and observing. No treatment was initiated or directed at seizures. No recurrence of seizures was noted during the hospital stay. No other issues or complications were documented.
 
The health plan's determination of medical necessity is upheld in whole.