Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Seizures
Treatment: Full hospital admission
The health plan denied the requested full hospital admission as not medically necessary. The health plan's determination is upheld.

The patient is a male without a significant past medical history who presented to the emergency department after his first episode of seizure. The patient worked at a cafeteria in the school, and while working, he felt his eyes fluttering and his left arm convulsing. The next thing he remembered was waking up on a stretcher. According to the bystanders, he was convulsing for 3 minutes but had no urinary incontinence or tongue biting. The patient felt confused afterward but was unsure for how long.
When seen by the admitting physician, the patient denied any recent fever, chills, or cough. The patient denied any alcohol, tobacco, or illicit drug use.
When seen by the admitting physician, he was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. He had intact distal pulses, with no edema, tenderness, cyanosis, or clubbing. He was awake, alert, and oriented x3 with no gross motor or sensory deficits. Cranial nerves were within normal limits. His skin was warm and dry, with no skin rashes.

The patient was admitted to the hospital with a new onset of seizures. A magnetic resonance imaging (MRI) of the brain was performed and demonstrated no acute changes or enhancing intracranial pathology. In the hospital, the patient was seen by a neurologist who recommended obtaining an MRI of the brain, electroencephalogram (EEG), and toxicology screen. The EEG came back abnormal with seizure-like activity, therefore before discharge, the patient was started on the antiepileptic medication Keppra. In the hospital, the patient remained seizure-free.
At issue is the medical necessity for the requested health service/treatment of a full hospital admission.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
At the time of the initial evaluation, the patient was awake and alert. He was hemodynamically stable and had no signs of a central nervous system infection. There was no evidence that he had focal neurologic signs. Per history, this patient had only one single episode of seizure on the day of admission. Reportedly, he totally recovered from the seizure by the time he was seen by the admitting physician, and the imaging studies did not show any acute abnormalities that required intervention. There was no evidence that the seizures were associated with significant electrolyte abnormalities. There was no evidence that the patient had any unstable concomitant conditions that would necessitate admission at the acute inpatient level of care.
Taking into consideration all these facts, I do not see clear evidence that either the severity of the patient's condition or the complexity of the services provided justified admission at the acute inpatient level of care. Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Admission at an alternate level of care would have been absolutely reasonable.