Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient admission. 

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

The patient is a female. She was brought to the emergency department by ambulance  after her parents found her on the floor with her right arm shaking and her stating that she felt "weird" and complaining that she was unable to move. Loss of consciousness, head trauma, tongue laceration and incontinence were denied. The patient had not had any similar episodes prior to this. The patient reported that within approximately one hour, she was able to regain her motor function and was able to walk without difficulty but she remained lethargic. The patient did have history of anxiety and possible panic attacks in the past, but her medical history was otherwise unremarkable. 

In the emergency room, the patient's EKG (electrocardiogram) and CT (computed tomography) scan were unremarkable, and electrolytes were within normal limits. Her exam was essentially unremarkable other than lethargy, but the patient became awake and alert when prompted. No neurological deficits were observed, but it was noted the exam was limited by the patient's cooperation. It was noted there were no signs of an infectious process. It was noted the patient could have had new-onset focal seizure. Neurology workup was recommended, and the patient was admitted. EEG (electroencephalogram) was also recommended. 

The following day, it was noted that the patient was doing well and appeared to be back to her baseline with resolved tiredness and fatigue. She was neurologically stable. Brain MRI (magnetic resonance image) was essentially unremarkable. EEG (electroencephalogram) was also unremarkable. No further seizure-like activity was noted. Urine culture was obtained to rule out infectious etiology. 

The patient was discharged and recommendations for outpatient neurological follow-up. It was also noted that a behavioral etiology had not been ruled out. No medications were prescribed. 

No, the Inpatient admission was not medically necessary. 

In order to be considered medically necessary, the services and/or supplies must be necessary for the diagnosis, care, or treatment of the illness or injury. In this case, the patient had her first unprovoked seizure, which resolved. The patient was neurologically stable in the emergency room. The patient's neurological needs included neurological examination by a physician, basic blood work for glucose and electrolytes, as well as brain imaging such as CT (computed tomography) or MRI (magnetic resonance image). This extent of care could have been done at a lower level of care without any need for acute inpatient admission. There was no evidence of status epilepticus, hemodynamic or neurological instability, fever or any signs of infectious process, and there was no need in neurosurgical intervention or frequent neuro checks. The vast majority of cases of first unprovoked seizure are managed on an outpatient basis, according to everyday clinical practice and medical literature. Therefore, inpatient admission was not medically necessary. 

The patient was neurologically stable, and there was no evidence of increased intracranial pressure or ongoing status epilepticus. Therefore, acute inpatient stay was not medically necessary.