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 with history of neonatal seizure, developmental delay, and asthma.  He was brought to the emergency department after having a tonic-clonic seizure, during which he had generalized shaking and unresponsiveness.  There was no tongue biting or urinary incontinence.  The seizure resolved after approximately one minute, but afterwards he complained of headache and dizziness.  The patient's last seizure prior to this was during his neonatal period.  He was fairly compliant with his anti-epileptic medication, but he had missed a dose the day prior to this current seizure.  Electroencephalogram (EEG) in the past had shown no seizure activity, but magnetic resonance image (MRI) of the brain in the past reportedly showed multiple areas of infarction.   

While in the emergency room, the patient was administered Keppra as well as Zofran and Toradol.  On exam, he had mild hypotonia to his limbs, a mild wide-based gait and mild ataxia.  Computed tomography (CT) scan of the head in the emergency room showed no evidence for acute hemorrhage but did show chronic left inferior frontal infarction.  A recheck of the patient showed him to have had an episode of bright red blood with vomiting, and a tongue injury to the left side of the tongue was noted without any active bleeding.  The patient was admitted due to likely breakthrough seizure in the setting of a missed Keppra dose for a video electroencephalogram (EEG) and close monitoring.  According to the emergency room records, the admitting physician felt there was significant risk for short-term decompensation and high likelihood of recurrent seizure.  Video electroencephalogram (EEG) showed abnormal findings with generalize slowing, left frontotemporal sharp waves and seizure out of sleep with diffuse onset.  Upon discharge the following day, the patient's mother was advised on the importance of administering the patient's medications as prescribed.  Pediatric neurology follow-up was recommended as well as an outpatient magnetic resonance image (MRI).

No, the proposed treatment is not medically necessary.

The patient has known diagnosis of epilepsy.  His epilepsy has been clinically stable while the patient takes the medicine prescribed regularly.  Due to missed Keppra dose, breakthrough seizure occurred.  The patient's baseline electroencephalogram (EEG) is abnormal, which is typical for many epilepsy patients.  The patient does not have any history of repetitive or recurrent seizures, multiple seizures in the same day, and no history of status epilepticus.  The patient has recovered from his seizure completely while in the emergency room.  Considering that the patient's neurological examination was at his baseline, vital signs were stable, neuro imaging was normal, hospital admission was not expected to improve the patient's health in any way, and managing the patient's condition at lower level of care was not expected to jeopardize his well-being.  According to neurological peer-reviewed medical literature, generally accepted management of breakthrough seizure in a known epilepsy patient include stabilization of the vital signs and neurological status, correction of the two therapeutic levels of antiepileptic medication, as well as antiepileptic medication dose adjustment.  Hospital admission, with or without video electroencephalogram (EEG), is not within generally accepted management of breakthrough seizure, according to the medical literature.  Therefore, the proposed inpatient admission was not medically necessary.

The patient's breakthrough seizure could have been managed at a lower level of care, and inpatient acute care admission was not medically necessary.