Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizures.
Treatment:  Inpatient Hospital Stay.
The health plan denied the inpatient hospital stay.  
The determination is upheld.

The patient is a male who initially presented to the emergency department with concerns for a seizure episode after hemodialysis. Pertinent history included seizure disorder, prior cerebrovascular accident, hypertension, and end-stage renal disease. Initial vital signs revealed a temperature of 98.3 Fahrenheit, a heart rate (HR) of 94 beats per minute (bpm), a blood pressure (BP) of 159/92 millimeters of mercury (mmHg), a respiratory rate (RR) of 20/minute, and a peripheral capillary oxygen saturation (SpO2) of 90 percent (%). Initial examination documented the patient as alert, awake, oriented, and with a Glasgow Coma Scale (GCS) of 15. Initial laboratory testing did not reveal severe electrolyte abnormalities. A computed tomography (CT) scan of the head did not reveal evidence of acute intracranial abnormality. The patient was placed in the hospital thereafter. Nephrology was consulted and noted no indication for hemodialysis. Epileptology was consulted whom recommended initiating oral lacosamide and discontinuing Keppra and clobazam and recommended obtaining an electroencephalogram (EEG). The EEG did not reveal acute epileptiform activity. The patient was discharged following the study.

At issue is the medical necessity of the inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

Based on the clinical documentation provided, evidence-based literature, and standards of care, the acute inpatient level of care was not indicated as medically necessary for the entire admission.

The American Academy of Family Physicians (AAFP) published guidelines regarding the evaluation and management of seizure, mainly first known episode. They note that the patient history and physical examination should focus on events directly preceding the seizure, the number of seizures in the past 24 hours, the length and description of the seizure, focal aspects (unilateral movements, eye deviation, head turning to one side), length of the postictal period, and the neurologic examination. This allows proper categorization as well as etiology identification and recurrence risk. Thereafter, in agreement with the American College of Emergency Physicians (ACEP), a Computed tomography (CT) scan of the head with and without contrast should be performed to look for structural lesions. Both the AAFP as well as the ACEP note that stable patients who have returned to baseline neurologic status in the emergency department may be discharged and scheduled for outpatient neurology if follow-up can be ensured. Additionally, laboratory tests can be performed but should be tailored to the individual patient and driven primarily by findings from the history and examination (glucose level in a diabetic, liver function tests/ammonia in a cirrhotic).[1]

Moreover, clinical indications for acute inpatient level of care were not met. The patient did not have hemodynamic instability, status epilepticus, brain disorder (tumor, edema, hydrocephalus, encephalitis, meningitis) that requires monitoring or intervention available only at the inpatient level of care, brain insult (severe trauma, stroke, drug toxicity, withdrawal) that requires monitoring or intervention available only at the inpatient level of care, cardiac arrhythmias of immediate concern, new onset seizure (first seizure) without return to baseline neurologic function within 30 minutes after seizure, persistent altered mental status, new focal neurologic deficit (post seizure), metabolic disorder that persists despite observation care treatment, recurrent seizure without a known seizure disorder, antiseizure medication that requires initiation at an inpatient level of care, cerebral bleeding, or increased intracranial pressure.[2]