Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure.
Treatment: Inpatient admission.	

The insurer denied coverage for inpatient admission.  The denial is overturned.

This case involves a patient with a request for inpatient admission. The patient presented to the emergency department after sustaining a fall and hitting their head on a bus during a motor vehicle accident. It was noted that the patient had a history of cerebral palsy, seizures, migraines, nystagmus, sickle cell trait, and asthma. The patient reported blurred vision and weakness that began after hitting their head over 24 hours ago, noting symptoms that were similar to when they had a seizure in the past. It was noted that the patient was compliant with Keppra at home and previously had a seizure with similar presentation. On exam, the patient was alert and oriented x 3, had regular heart rate and rhythm and clear lung sounds were present on auscultation, +4/5 motor strength was noted in the left extremities while +(plus)5/5 motor strength was noted in the right extremities, and horizontal nystagmus was also noted. Computed tomography (CT) of the head noted no acute abnormalities. Electrocardiogram (EKG) noted normal sinus rhythm with a heart rate of 56. The patient was given a differential diagnosis of breakthrough seizure. The treatment plan included admitting the patient for further evaluation of left sided weakness and seizure activity, as well as magnetic resonance imaging (MRI) and electroencephalogram (EEG). A progress note indicated that the patient had significant nystagmus and slight tongue deviation to the left on neurological exam, as well as significant left lower extremity weakness and decreased sensation. No acute overnight events were documented. The treatment plan included MRI with sedation due to history of pseudo seizures when attempting MRI, as well as continuation of Keppra and Vimpat. It was noted that the MRI was cancelled due to a history of seizures during MRI. The patient was noted to be stable with improving symptoms. The treatment plan included EEG, cardiac monitoring, early physical and occupational therapy evaluation, venous thromboembolism (VTE) prophylaxis, pain management, continuation of Keppra and Vimpat, and an outpatient neurology follow-up visit. An EEG report indicated a normal EEG, however, it was noted that the EEG did not exclude the diagnosis of seizures or epilepsy. The patient was discharged home when it was determined that a stroke was unlikely.  

A provider appeal letter indicated that the patient required inpatient admission as the patient presented with dizziness, blurred vision, nystagmus, slight tongue deviation to the left, and significant left lower extremity weakness that was worse than the patient's baseline weakness. It was stated that the admission was needed to rule out stroke versus seizure, and further evaluation with MRI was planned, however, the MRI was cancelled due to a history of seizure during MRI. The patient was subsequently discharged home when the patient's symptoms were no longer worsening, the patient remained hemodynamically stable, and was cleared for discharge. 

A letter of medical necessity indicated that the inpatient admission was medically necessary, as the patient required serial laboratory and vital sign monitoring completed within 4 hours, as well as intravenous (IV) fluids. It was also stated that the patient required acute inpatient care due to concern for epilepsy, stroke, transient ischemic attack, seizures, and traumatic brain injury as the patient sustained a fall and had dizziness, and ongoing left-sided weakness, with a history of cerebral palsy and seizure. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is substantiated.