Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shaking of arm and leg
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female who was previously healthy. She was admitted after presenting to the ER (emergency room) for evaluation shaking of the left arm and leg.  She noticed her left leg started moving involuntarily for two minutes. She was unable to speak. Her leg felt heavy. This eventually resolved. Her family came to help and noted she had left-sided upper and lower extremity shaking lasting 30 to 40 seconds and she felt weak afterwards. On the way to the ER (emergency room), she had a third episode lasting 30 to 40 seconds. Review of the patient's history shows that she had two prior similar episodes a year ago.

In the ER (emergency room), the patient was in pain in the left leg with a heart rate of 126, blood pressure 125/76, and a temperature of 99.4F. Her examination was unremarkable with no focal neurological deficits. She had a head CT (computed tomography), which was unremarkable. CBC (complete blood count) and CMP (comprehensive metabolic panel) were unremarkable except for alkaline phosphatase of 295.

There was concern about seizures, so patient was admitted for further evaluation. She had an EEG (electroencephalogram), which was normal, and a plan for an MRI (magnetic resonance imaging) brain as an outpatient.  She was started on carbamazepine.  She was discharged home with a plan for continued follow up care.

The plan denied the acute inpatient care, presenting an argument the patient's condition did not meet admission criteria for MCG (Milliman Care Guidelines).   The provider appealed the denial stating the patient met Interqual admission criteria.  This review is in regards to the medical necessity for the inpatient admission.

Yes, the Inpatient admission was medically necessary.
In this case, the patient had three events that were suspected to be seizures, all within one day.  She had focal symptoms without explanation.  Based on published guidelines and standard of care, new onset seizures should be evaluated promptly with neuroimaging and EEG (electroencephalogram).  Per standard of care, patients requiring admission for new onset seizures are those patients with high risk of morbidity and mortality from seizure recurrence or other complications and who require further evaluation with EEG (electroencephalogram) and a need for starting medications.  One cause of morbidity and mortality is recurrent seizures. In this case, the patient had three seizures within 24 hours. This place the patient high risk of having subsequent seizures, which could place her at higher risk of morbidity and mortality.  As the patient was at higher risk of seizure recurrence and required course monitoring and urgent evaluation, inpatient status was necessary.   In this case, the patient had three seizures on one day, required evaluation with an EEG (electroencephalogram) and initiation of an anticonvulsant medication.  Therefore, the acute inpatient admission was medically necessary.

The plan denied this admission.  The plan based its decision on MCG (Milliman Care Guidelines) criteria, which is a generally accepted guideline for determining need for inpatient level of care.  However, Interqual criteria are also generally excepted guidelines for determining inpatient level of care, and the patient met these criteria. Both of these publications provide guidelines. However, as guidelines, they provide guidance, but do not consider individual aspects of the patient and happen to have differing standards, and thus, final decisions should consider generally accepted medical standards. The denial from the plan did not consider Interqual criteria or generally accepted standards of medical practice as discussed in question number two.  In summary, the plan did not consider alternative criteria or general standards of care in the decision to deny care.