Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pre-approve inpatient video EEG monitoring. We decided that the Plan does not have to pre-approve inpatient level of care.

You asked the Plan to pre-approve inpatient video EEG monitoring. You say that the records provided should support the necessity of the service in dispute. The Plan says that the requested services does not meet inpatient criteria. The service can be done in observation level of care.

We decided that the Plan has to pre-approve video electroencephalogram (EEG) monitoring.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient video EEG monitoring. Our reviewer says that the enrollee meets the criteria for the EEG monitoring. Our physician reviewer found in this case the enrollee has a history of possible epilepsy. She (more recently) was seen for neurology evaluation of possible seizures (versus non seizure events). Extended EEG monitoring is clinically appropriate for this condition/setting. However, provision of this service in the inpatient level of care would not be a setting appropriate to the enrollee's medical needs and condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient video EEG monitoring have been met. Therefore, we decided that the Plan has to pre-approve video electroencephalogram (EEG) monitoring.

We also decided that the Plan does not have to pre-approve inpatient level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient level of care. Our reviewer says that the enrollee does not meet the criteria for inpatient level of care. Our physician reviewer found the enrollee is not noted to currently be on an anti-convulsant at this time. There would therefore not be a need to wean the enrollee off their medication (which is commonly done in the inpatient setting given the risks associated). There were no other indications within the records provided that the enrollee has a condition for which the inpatient level of care would otherwise be necessary for the completion of said service. In as much the inpatient level of care itself would not meet the Medicare definition of medical necessity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient level of care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.