Appeal type: Medical necessity
Decision: Upheld

Diagnosis Seizure

Treatment Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is Upheld

The patient is a female toddler. The medical records indicate the patient has seizure activity for which was admitted inpatient for medical management. The patient is under treatment with Keppra 200 milligram (mg) twice a day; however, the mother admits that the patient missed two (2) doses, while at home. 

The patient has a past medical history positive for agenesis of corpus collosum, microphthalmia of the right eye and left eye congenital cataract with eye surgery at four (4) months of age.

The patient's vital signs were within normal limits and showed a blood pressure (BP) of 99/60, a pulse of 121, a temperature of 96.3 degrees Fahrenheit (F) rectally, respirations of 21 and an oxygen level of 100% on room air (RA). The hospital record noted that the patient was "not in acute distress" and documented that the patient's abnormal labs were likely due to recent seizure as a repeat blood gas was documented to be normal. 

The patient was noted to be stable and was discharged after 2 days.

The patient was admitted following witnessed seizure activity. The patient was reported to be taking Keppra, twice daily, while at home; however, it was noted that two (2) doses were missed. The patient's vital signs, while in the hospital, were stable as there are no hospital notes, provided for review, that indicate the patient had an unstable blood pressure, heart rate or oxygen level. There is nothing to support instability or continued seizure activity following treatment with medication. Inpatient clinical notes, laboratory values and discharge paperwork indicate that the patient could have been treated on an observation level of care and the inpatient stay was not medically necessary for this patient.

"A seizure represents the uncontrolled, abnormal electrical activity of the brain that may cause changes in the level of consciousness, behavior, memory, or feelings. Convulsive concussion, convulsive syncope, movement disorders, rigors, sleep-related events, or psychogenic non-epileptic spells are all in the differential diagnosis of an event. Seizures can classify as partial or generalized. In a partial seizure, the most common seizure type in adults, one area of the cortex activates first and may manifest through simple symptoms such as a motor or sensory phenomena. Generalized seizures result from diffuse cortical activation at seizure onset or generalization of partial seizure activity." (Huff JS, Murr N. 2023).

"Once a patient has been started on anti-seizure medications, education of the patient is vital. In addition to the prescribing practitioner, both the patient's nurse and pharmacist should educate the patient on adherence on medication compliance." (Subbarao, B. S., dt al., 2022).                                                         

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