Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Seizures. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld. 

This case involves a man with a possible history of alcohol abuse who presented to the hospital with seizures, which occurred around 7:30 am on the presentation day, lasting for 3 to 6 minutes. These were witnessed by the patient's girlfriend, who tried to wake him up. The patient states he could hear her voice but could not respond. There is no evidence of fecal or urinary incontinence or tongue biting. A similar episode occurred two years before this presentation, for which he did not seek medical care. After the event subsided, the patient felt dizzy, but the symptoms resolved by the time he arrived at the hospital. The patient reports drinking 1-2 alcoholic beverages every two weeks. 
Vital signs on admission included a temperature of 97.1F., a pulse rate of 67 beats per minute (bpm), and a blood pressure of 95/63 millimeters of mercury (mmHg). Respirations were 18/minute. On exam, there are no major abnormalities documented. 
A chest x-ray in the emergency department (ED) was negative, and so was a noncontrast head computed tomography (CT). Electrolytes and renal function appeared stable. The patient was admitted for a brain magnetic resonance imaging (MRI) and an electroencephalogram (EEG). The alcohol level was negative. A urine drug screen was also requested. Furthermore, the medical team tested the patient for human immunodeficiency virus (HIV), Gonorrhea (GC), and Chlamydia. 

The EEG was performed and showed no evidence of epileptiform discharges. The brain MRI was also negative for epileptogenic focus. The vital signs remained stable throughout the hospital stay. The medication record reveals that the patient received 1000 mg (milligrams) of Keppra on the day of admission, which appears to have been discontinued later in the hospital stay. HIV, GC, and Chlamydia tests were negative. The patient was not released on any antiepileptic medications. 

At issue is the medical necessity for an inpatient level of care. 

I uphold, in whole, the health plan's determination of medical necessity. 

No. The requested health service of an inpatient stay was not medically necessary for this patient. Based on the provided documentation, there are no clinical indications for admitting this presentation under the inpatient level of care. The patient presented with a witnessed seizure at home, with no recurrence in the hospital. Brain MRI and EEG were normal, and the patient did not require antiepileptic medications on discharge. There is no clear evidence that the patient experienced a true seizure, as pseudo seizure activity was also contemplated in the differential. There were no recurrences of seizure activity in the hospital; the patient remained hemodynamically stable and did not require prolonged monitoring or treatment. The type of presentation described in this case is typically managed under an alternate level of care, with subsequent outpatient follow-up. The medical literature supports this approach. I have included the representative articles.