Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Seizures.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.  
The denial is overturned.

This case involves an adult with a history of seizures, who was seen in the emergency department for evaluation of nausea, lightheadedness, and dizziness. When she was seen, she was already taking Vimpat 100 mg (milligram) oral tablet and on assessment, was described as slow to respond and confused, but she was able to answer questions. While in the emergency department, the patient had a generalized tonic-clonic seizure and was subsequently admitted for further work-up. The emergency department report stated that the patient had been hospitalized on 2 prior occasions in the past 1.5 months secondary to seizures. Each time, she presented in a similar fashion. The physician stated that the reason for the hospital admission was because of concerns that she was having breakthrough seizures. The patient could not be safely discharged home and required further management. The patient remained on inpatient status for testing and treatment and was discharged the following day.  

The Milliman Care Guidelines state that inpatient care for individuals with seizures include those who have one or more of the following to include evidence of hemodynamic instability, status epilepticus, a brain disorder that requires monitoring or intervention available at inpatient level of care, etiology that requires monitoring or intervention available only at inpatient level of care or that persists despite observation care, when there is altered mental status that is severe or persistent, new focal neurologic deficit after a seizure, when there is a metabolic disorder that persist despite observation care, when there is a recurrent seizure (for example, during emergency department or observation care) and one or more of the following is present to include the patient is not known to have a seizure disorder, has recurrent seizure of a different seizure types and previously known seizure disorder, or the patient is with baseline or infrequent seizures and recurrent not thought to be due to readily modifiable etiology. Patient care may also be indicated for those individuals when outpatient antiepileptic regimen cannot be established, when there is triple bleeding, hydrocephalus, or vasospasm monitoring needed or increased intracranial pressure or cerebral edema monitoring. Observation care may be indicated for those individuals who have one or more the following to include vital sign abnormality, when they have had a first seizure, when there is a specific etiology requiring short-term observation, treatment, or correction, medication initiation or adjustment that requires brief observation, and when there is altered mental status upon postictal presentation to the hospital. While the physician did not specify that the seizure that occurred during the emergency department assessment was of a different type than previously known, given the generalized tonic-clonic seizure and presenting symptoms of nausea, lightheadedness, and dizziness, it was appropriate to admit the patient for further work-up, given that she was having breakthrough seizures despite pharmacological treatment.  

After a review of the provided information, the inpatient admission was medically necessary.

Based on the above, the insurer's denial must be overturned. 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.