Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This case involves a pre-school aged patient. Emergency department (ED) note reported the patient arrived with left head turn, left eye deviation, and unresponsive. After administration of intravenous (IV) Ativan the patient began having purposeful movement with resolution of left gaze and no gross deficits. The patient had a known seizure disorder and was on Keppra. The patient had 4 back-to-back episodes consistent with his normal seizure type. Given the 4 episodes in 1 hour treatment plan was to load with Keppra and consult neurology. Pediatric neurology recommended admission overnight for observation as well as to increase Keppra dose. History and physical noted the patient had 2 seizure episodes that morning and had another episode with Emergency Medical Services (EMS) lasting a few seconds. It was noted there were 2 similar episodes while in the ED. The patient had tested positive for Coronavirus (COVID) 1-2 weeks ago and symptoms had now resolved. Keppra was increased after the patient's last seizure episode. The patient was admitted for management of breakthrough seizures. Neurology consultation reported exam was without focal neurological deficit. It was noted that episodes were similar as prior seizures and there was no concern for alternate intracranial process. Treatment plan was to increase Keppra and follow-up upon discharge. Discharge summary reported the patient remained afebrile and hemodynamically stable with no recurrence or seizures during his hospital stay. The determination letter reported the prior denial of inpatient admission was upheld as the patient had a history of seizures and clinical presentation was not unstable to warrant admission. Appeal letter stated the patient had a history of seizure disorder/multifocal epilepsy as well as autism. The patient presented to the emergency room by ambulance due to multiple episodes of vomiting that morning as well as 2 seizures. The patient was actively seizing in the emergency department and Ativan was administered. The patient was recommended for admission for close monitoring and to increase the maintenance dosing of Keppra.

Milliman Care Guidelines (MCG) recommends admission for seizure disorder when there are recurrent seizures without known history, or seizures of a different type, or there was a baseline of infrequent seizures and recurrence was not thought to be due to readily modifiable etiology. In this case, the patient had a known seizure disorder. Providers indicated that seizure types were consistent with history and further diagnostic work-up was not needed. The patient also had a recent history of subtherapeutic drug level and Keppra was increased. After initial treatment with Ativan, symptoms resolved. The patient could have received treatment at a lower level of care such as observation. 

Based on the above the insurer's denial must be upheld. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for inpatient admission is not substantiated.