Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned.

The patient is a female. She has a known history of agenesis of corpus callosum, micro ophthalmia of the right eye and a seizure one year prior. The patient had not completed evaluation for that seizure due to a missed appointment, and she was not taking anticonvulsant medications. She was admitted for evaluation of seizures.

The patient presented to the emergency room after having three consecutive seizures. She woke up and vomited. This was followed by staring off for approximately one minute. She was unresponsive during this time. She then had generalized tonic-clonic shaking for five minutes. She had a third episode while emergency services were preparing her for transfer to the hospital. The third event lasted for four minutes. She was given Versed. She was taken to the ER (emergency room), where she was described as sedated, but she could be roused.

The patient's vital signs were stable. She was treated with a loading dose of intravenous Keppra and IV (intravenous) fluids. Labs including CBC (complete blood count), BMP (basic metabolic panel), venous blood gas, urinalysis, blood in urine cultures and testing with viral panels. The labs did not show major metabolic derangements. The decision was made to admit her to the pediatric intensive care unit, due to presenting with status epilepticus and prolonged post-ictal state.

The patient required neuro checks every 3 hours (later changed to every 4 hours). While admitted she recovered mental status and was transferred to the general pediatric floor. She had a neurology consultation. She underwent evaluation with electroencephalogram. She was continued on Keppra. There were no further complications.

The patient was discharged home with a plan for neurological follow up and continued Keppra use. This admission was denied by the plan due to lack of meeting plan guidelines for medical necessity (Milliman Care Guidelines Guideline 25th Edition, Seizure, Pediatric.). The treating facility appealed the decision in a letter stating the patient suffered from status epilepticus, and her care could not have been provided at a lower level than admission level. This review is in regards to the inpatient hospital admission.

Yes, the Inpatient Hospital Admission was medically necessary.

Per generally accepted standards, patients with known seizures may require inpatient level care in certain situations. These situations include times that the patient has 2 or more seizures within 24 hours or a change in seizure type. In addition, patients presenting with status epilepticus or with prolonged alteration of mental status may require inpatient care (Galizia, Bank).

In this case, the patient had a known prior seizure but had not been taking anticonvulsant medications, as she was still pending evaluation for that seizure. She had three seizures in close time proximity, which was a medical emergency in the spectrum of both status epilepticus and acute repetitive seizures. The patient required both a benzodiazepine and maintenance anticonvulsant medication. In addition, the patient had a prolonged post-ictal state. Based on her presentation of status epilepticus/acute repetitive seizures, the patient was at elevated risk of seizure recurrence (VanHaerents). Thus, the patient required admission level care with close monitoring (with neuro checks every 3 hours in this case). The patient could not have been cared for in observation level, as the patient required frequent neuro checks and was at heightened risk of seizure recurrence and neurological decline. Thus, the patient required acute inpatient level care due to the acuity of her illness.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient was admitted after an episode of status epilepticus. She was at high risk of neurological decompensation due to a high risk of seizure recurrence.  Pediatric patients presenting after status epilepticus generally will required acute inpatient level care. The plan argued that the patient could have been cared for in observation level care. However, this level of care was insufficient to meet her needs.