Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System / Neuromuscular Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient Hospital Stay
The denial was: UPHELD

This case involves a male with a history of seizures treated with Keppra, Dilantin, and Trileptal who presented to the emergency department with a breakthrough seizure event. He was seen in the emergency department and loaded with intravenous (IV) Keppra. He was discharged from the emergency room (ER) back to the adult group home; however, upon arriving, there experienced multiple seizures. Emergency Medical Services (EMS) was called back to the facility, and the patient had additional seizures in the ambulance. He was treated with a dose of IV Ativan, and tele-neurology was consulted. The recommendation was to load the patient with 1000 milligrams (mg) of IV Dilantin. On arrival, he was confused, not answering any questions. The temperature was 98 degrees, with a pulse rate of 70, and blood pressure 120/83. Mental status was described as somnolent. The rest of the physical exam was unremarkable. Laboratory studies were relatively unremarkable. Dilantin level was high at 26. Urinalysis was normal. Electrolytes and renal function are unremarkable.

Computed tomography (CT) scan of the head without contrast shows no intracranial hemorrhage or large stroke.
The patient was admitted to the hospital with a principal diagnosis of breakthrough seizure. He was admitted to medicine monitored bed for observation. Seizure and aspiration precautions were initiated, and neurology was consulted.
The patient was seen by neurology the following day and note that the patient experienced 9-10 seizures within the 24-hour time frame. Per the neurology note, the patient was admitted to the critical care unit. There were no additional seizures noted. The neurologist recommended continuing the same dose of Dilantin Trileptal and Keppra but increase the dose of zonisamide to 300 mg daily. They also recommended monitoring for an additional 24 hours to ensure that the patient remains seizure-free. At this point, the neurologist signed off.
The following day, the patient was resting in bed with no seizures since admission. Vital signs remained stable. Earlier in the morning, he experienced an episode of arm and hand jerking. Laboratory studies remained unremarkable. Continued management to ensure no recurrence of seizure activity was instituted.
The physical therapist evaluated the patient and noted an instance of arm tightening and the patient stopped walking for a few minutes. He was able to follow commands through the whole incident. He reported that this is a common occurrence when he gets frustrated even at the rehab facility. Otherwise, he did very well with physical therapy and was deemed stable for discharge.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for the patient. This is a patient with longstanding seizure history, who experienced breakthrough seizures and required adjustment of antiepileptic medications. After the series of seizures were halted with Ativan and a loading dose of Dilantin, there were no additional seizures while in the hospital. As a result, there is not a clinical indication for admission to inpatient hospitalization. Vital signs remained stable; there was no evidence of status epilepticus. There were no signs of infectious causes or cardiac arrhythmias. Laboratory studies were normal; there were no significant metabolic disorders. From the time of admission until discharge, the patient did not have any recurrence of the seizures. He had some hand tightening and twitching, while able to follow commands with physical therapy, which is not consistent with a seizure event. Neurology essentially signed off his case within 24 hours of admission. Imaging of the brain was normal. As a result, the patient could have been managed at a lower level of care status, which would have been able to provide the same outcomes for this patient as an inpatient.