Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a past medical history significant for seizure who required multiple admissions to the hospital due to breakthrough seizures and subtherapeutic Keppra levels, also a history of alcoholism, hypertension, microcytic anemia, subdural hematoma, and schizoaffective disorder who was brought to the hospital after he had a witnessed seizure.

The patient was admitted to the hospital with a breakthrough seizure due to medication noncompliance. Alcohol withdrawal was also suspected.
The patient received treatment with Keppra, Ativan, and a bolus of intravenous fluids. Neurology consultation was requested. The patient received medications for hypertensive urgency.
Another clinical diagnosis was high anion gap metabolic acidosis, which was attributed to possible alcohol intoxication versus lactic acidosis due to dehydration. In the hospital, the patient was seen by a neurologist who recommended continuation of treatment with Keppra at home as well as follow-up with a neurologist as an outpatient. The blood pressure stabilized very quickly after the patient received clonidine and Lasix in the emergency department along with his home dose of nifedipine.
The patient received potassium supplements because of hyperkalemia.
The high anion gap metabolic acidosis was attributed to alcohol. It resolved after the administration of intravenous fluids.
According to the medical records, the patient had a history of schizoaffective disorder that was stable without any suicidal or homicidal ideations. Reportedly, the patient was not on any medications for his schizoaffective disorder. Since the patient's clinical condition significantly improved, he was discharged from the hospital.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
Based on the nationally accepted standards of care, the admission to the hospital at the acute inpatient level of care is usually indicated for patients who present with seizures and hemodynamic instability, status epilepticus, severe brain disorder such as a tumor, hydrocephalus, trauma, infection of the central nervous system such as meningitis or encephalitis.
The admission at the acute inpatient level of care is also indicated for patients who present with seizures and severe or persistent altered mental status, new focal neurologic deficits.
Metabolic disorders that persist beyond the observation period are also a clinical indication for admission at the acute inpatient level of care. However, in this clinical case, the metabolic abnormalities that manifested in the high anion gap metabolic acidosis were short-lived and completely resolved after initiation of treatment with intravenous fluids.
There was no evidence that the patient had recurrent seizures after he received treatment with Keppra in the emergency room (ER).
Taking into consideration all these facts, the admission for monitoring was definitely warranted to ensure that the patient's seizures stopped after receiving treatment with antiseizure medication Keppra, also to watch the patient for possible alcohol withdrawal symptoms, and to ensure resolution of anion gap metabolic acidosis. However, the patient could have been safely and appropriately been managed at a lower level of care status.