Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for continuous electroencephalography (EEG) monitoring at a tertiary level facility, a brain magnetic resonance imaging (MRI) while the patient is ventilated at a tertiary facility, and treatment at a tertiary level facility.At issue is whether continuous EEG monitoring is medically necessary to treat the patients condition. If so, is it medically necessary to be performed at a tertiary level facility? Additionally, is a brain MRI while the patient is ventilated medically necessary to treat the patients condition. If so, is it medically necessary to be performed at a tertiary level facility? Is treatment at a tertiary level facility medically necessary to treat the patients medical condition?Anoxic brain injury is most often associated with clinical events such as cardiac arrest. Anoxic brain injury is due to decreased oxygen delivery to the various regions of the brain. When this occurs secondary to cardiac arrest, there is global hypoxia leading to vascular injury, as seen in this patient. In this case, evidence of hypoxic injury was confirmed on CT imaging. During the patients hospitalization, EEG was performed, with nearly flat waves and no evidence of epileptic activity. Wei and colleagues conducted an analysis which concluded that, although there was prognostic value in MRI, the examination utility of an MRI decreased after six days. There is no evidence to support additional MRI imaging a month after the inciting event is clinically indicated or is medically necessary, especially when evidence of anoxic injury is present on CT. Scarpino and colleagues conducted a study that showed EEG within the first 24 hours after cardiac arrest can accurately predict poor neurological outcome at six months. However, a review by Sandroni and colleagues suggests that while EEG performed early in the disease process had a low false positive rate, EEG performed later in the disease process demonstrated a higher false positive rate. Furthermore, there is no evidence to support continuous EEG monitoring in a patient who suffered a cardiac arrest greater than one month ago with previous EEG performed without any indication of seizure or seizure like activity. Transfer to a higher level of care (tertiary center) at this point in the patients hospitalization garners no support from the available data. Therefore, continuous EEG monitoring at a tertiary level facility, a brain MRI while the patient is ventilated at a tertiary facility, and transfer to a tertiary facility are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.