Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures. 

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a male patient with a history of seizures.  The documentation indicated that he was seen in the Emergency Department (ED) complaining of having multiple seizures.  The patient indicated that his last seizure lasted a few minutes and he had to sit on the bedframe per his mother.  The patient denied weakness or numbness.  The patient reported some forehead pain.  The patient has some vomiting but no abdominal pain.  The patient reported that he did not take his seizure medication the day prior.  The physical examination revealed that the patient was in no apparent distress.  The recommendation was made for the patient to undergo multiple laboratory studies.  The laboratory studies revealed no significant findings.  The recommendation was also made for the patient to undergo a computed tomography (CT) scan.  The patient's CT scan did not reveal any acute findings.  The patient was given intravenous (IV) medication and IV fluids.  The patient did not have any seizure-like activity within the ED.  The patient was admitted and recommended for further evaluation.  The recommendation was made for the patient to also undergo neurology consultation.  The documentation however indicates that the patient left the hospital against medical advice (AMA) the following day.

According to the Milliman Care Guidelines, the acuity of this case is considered to have required observation as the patient presented with a transient neurologic concern of seizures.  Upon arrival to the hospital, the patient was not considered to be in status epilepticus.  No further events concerning for seizures were noted during this patient's hospital stay.  Precautionary testing with computed tomography (CT) scan and electrocardiogram (EKG) were performed and these tests showed no abnormality.  No other interventions were medically necessary. The patient was described as interactive and was able to be leave against medical advice (AMA). The patient did not require an escalated level of care.

The current literature indicates that a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability.  Within the documentation it was noted that the patient presented with increased seizures and his symptoms resolved after some hydration and intravenous (IV) medication treatments.  However, the submitted documentation does not detail that the patient had a trial and failure of care at a lower level such as observation.  The documentation detailed that the patient was back at his baseline and elected to self-discharge.  Based on these clinical findings, the requested inpatient admission would not be the most appropriate level of care.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.