Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male admitted for evaluation and management of seizures and
discharged the following day. He had a history of developmental delays and
idiopathic hypotonia treated with outpatient speech, occupational and physical
therapies. He was in the car with his mother when she noted his eyes were rolled
back and he was drooling. He was unresponsive for three to four minutes. He had
a similar event approximately two weeks prior. 

In the emergency room (ER), the patient had tachycardia and was at his baseline
mental status. A head computed tomography (CT) and labs were unremarkable
other than aspartate aminotransferase (AST) of 80. The patient was admitted for
further evaluation and management. He had a neurological consultation and an
electroencephalography (EEG). The EEG (electroencephalography) was abnormal
due to generalized discharges. He was started on Keppra and discharged home
the next day. 

The inpatient admission was denied as not medically necessary due to the care not
meeting criteria for acute inpatient level care. The provider appealed this denial with
the argument that the care met Milliman Care Guidelines (MCG) inpatient stay
medical necessity criteria. This review is in regards to the medical necessity of the
inpatient admission. 

No, the proposed inpatient admission was not medically necessary. 

Based on clinical experience and standard of care, admission level care is
warranted in certain situations for patients with new onset or known epilepsy or
seizures. Generally, admission level care is required if there are multiple seizures
within 24 hours and if the seizures are longer than usual or of a different description
than usual and there is a need for urgent evaluation. Other situations that may
require acute inpatient level care include status epilepticus (seizure greater than 15
minutes), prolonged alteration of mental status (greater than two hours and if
atypical for the patient), unexplained focal neurological deficits on exam, a need for
multiple doses of benzodiazepines to abort seizures, continued maintenance
intravenous (IV) anticonvulsant treatment for seizures or intravenous treatment for
major metabolic derangements. 

In this case, the patient had a single seizure and had recovered normal mental
status. Neuroimaging was unremarkable, as were his labs. Thus, the initial workup
done before admission did not suggest an acute process such as meningitis,
encephalitis, or an intracranial lesion. The patient was clinically stable at the time of
admission. Although the patient required urgent evaluation with
electroencephalography (EEG) and to start on anticonvulsant medication, these
treatments do not require an inpatient level of care. The nursing and physician
documentation supports that the patient remained medically stable after the
admission. The monitoring did not require an inpatient level of care. 

In summary, the patient was medically stable at the time of admission and the
services ordered were of the intensity that did not require inpatient admission. Had
any complication or problem occurred or the diagnostic testing indicated an
emergent problem, the patient could have appropriately been converted to inpatient
status at that time. 

Thus, the acute inpatient level care was not medically necessary. 

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

The health plan denied the acute inpatient admission as not medically necessary as
the care did not require inpatient status. As discussed in above, the health plan's
decision followed current standards of care.