Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is the case of a male with a past medical history significant for a seizure disorder, alcohol abuse, cerebrovascular accident with chronic left-sided deficits, pulmonary embolism, and rectal cancer. The patient presented to the emergency department following a witnessed seizure at home. He previously took Keppra at home for his seizures but may have missed his afternoon doses. When he was initially assessed, blood pressure was 154/95 with a second reading at 179/89. Hemoglobin was 11.1 with hematocrit 34.3%. He was assessed by neurology with recommendations for admission to neuroscience. A final adverse determination letter denied the inpatient admission given that the report was of hemodynamic stability. The document did not indicate that the patient had repetitive seizures that were not controlled in the emergency department. An appeal was submitted indicating the patient required the inpatient stay with reports that the patient had been drinking heavily, he complained of headache, with elevated blood pressure, and laboratory results notable for magnesium 1.1. The indication was that he required acute inpatient care to be kept on seizure precautions given acute suspected focal seizure secondary to medication noncompliance versus alcohol withdrawal seizures in the setting of seizure disorders and alcohol abuse. 

The inpatient admission was not considered medically necessary for this patient. According to the Milliman care guidelines, the clinical indications for admission to inpatient care for a patient having seizures includes: must have 1 or more the following to include hemodynamic instability, status epilepticus, a brain disorder such as tumor, edema, trauma, hydrocephalus, encephalitis, meningitis, that requires monitoring or intervention available only at an inpatient level of care, or that the etiology is drug toxicity, withdrawal, non-adherence that requires monitoring or intervention available only at inpatient level of care or that persists despite observation care. If the patient has altered mental status that is severe or persistent, new focal neurologic deficit, metabolic disorder, recurrent seizures during the emergency department or observation care, outpatient antiepileptic regimen that cannot be established, cerebral bleeding, hydrocephalus, or vasospasm monitoring, or increased intracranial pressure or cerebral edema monitoring. In the case of this patient, he had a history of seizures and had previously taken Keppra but was noted to have noncompliance along with alcohol use that may have contributed to his seizure episode at home. Given the patient's past medical history, it would be reasonable to place him on observation care throughout the timeframe in question given that he had no additional seizures while in the emergency department. Given that his symptoms did not escalate, he could have been treated on a lower level of care and did not require inpatient admission for the timeframe in question.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.