Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a past medical history significant for seizures, pseudoseizures, hypertension, and depression, who was brought to the emergency room by ambulance after she had a witnessed breakthrough seizure while at home on the couch.
According to the history and physical (H&P) note, the patient did not remember the episode but denied any bowel or bladder incontinence, or tongue biting.
Reportedly, the patient had presented to the emergency department multiple times in the past with pseudoseizures, which were stopped by sternal rub and spraying saline to the face.
The patient stated that she was generally compliant with her medications. The last time she skipped her antiepileptic medications was approximately 1 week before the day of admission.
Reportedly, the patient had visited the emergency department 5 times within 1 month that preceded the day of admission. Her most recent hospitalization was two weeks earlier. At that time, she had a negative computed tomography (CT) scan of the head. She was evaluated by a neurologist and was recommended video electroencephalogram (EEG) as an outpatient.
She was also evaluated by a psychiatrist for depression and recommended to continue treatment for depression with her home medications as well as a follow up with a psychiatrist as an outpatient.
Reportedly, there was no information that the patient, in fact, followed up with a neurologist or psychiatrist as an outpatient.
At the time of the initial evaluation and during this hospital stay the review of systems was obtained and it was positive for seizures only.
When the patient was seen by the admitting physician, she was afebrile, blood pressure was 156/91, pulse rate 74, respiratory rate 18, and oxygen saturation was 100% on room air. The patient was resting comfortably, in no acute distress. Her head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The cardiovascular exam was unremarkable. Lungs were clear to auscultation. The abdominal exam was unremarkable. On the neuro exam, the patient had no focal deficits. Her cranial nerves were within normal limits. The patient had normal muscle strength throughout. The sensation was intact, there were no pathologic reflexes elicited. The patient's coordination was within normal limits.
Laboratory evaluation revealed that the patient's white blood cell count was 8.1, hemoglobin 13.5, hematocrit 40.9, platelets 265. Sodium was 141, potassium 3.6, blood urea nitrogen (BUN) was 7.0, creatinine 0.72, and glucose was 93. Creatine phosphokinase (CPK) was normal.
Electrocardiogram (EKG) demonstrated normal sinus rhythm, no ST-T changes.
The patient was admitted to the hospital with a diagnosis of breakthrough seizures versus pseudoseizures. The patient was initially admitted for observation.
Reportedly, she was found lying on the floor after an unwitnessed fall. At that time the patient denied loss of consciousness. Subsequently, she began having generalized convulsions, which appeared to be attributed to a pseudoseizure. According to a note from a physician after this episode, the patient could talk and moved all her extremities.
Following this episode, the patient was admitted at the acute inpatient level of care, because of the unwitnessed fall requiring further workup to rule out any traumatic injury.
According to medical records, the patient did not have other episodes of seizures.
Reportedly, the patient was awaiting a transfer to a different hospital for a video EEG. Apparently, the transfer to the hospital with video EEG capabilities never happened, and the patient was discharged from the hospital with recommendations to take antiepileptic drugs, to follow-up with a neurologist, and seek further evaluation in the hospital with video EEG capabilities.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. She could have been safely treated at a lower level of care status.
The review of the medical records did not demonstrate that there was overwhelming evidence that the patient had a seizure before she came to the hospital since there was no postictal state, no bowel or bladder incontinence, or tongue biting, and the patient had a normal CPK level.
During the hospital stay the patient had an unwitnessed fall that was not associated with loss of consciousness. Subsequently, she developed a tonic/clonic activity. At that time her vital signs were stable. This lasted for 30 seconds, and then the patient sat up in bed and stated that she was okay. The description of the generalized convulsion activity and lack of the symptoms typical for seizures such as postictal state made the probability of seizures pretty low. It was indicated in several notes that the patient most likely had a pseudoseizure.
 
The review of the medical records demonstrated that the patient most likely had pseudoseizures. This conclusion is based on the review of the patient's past medical history, the results of the physical exam, and a review of the laboratory studies and the diagnostic tests.
Apparently, the patient's prolonged hospitalization took place because of the attempts to transfer her to a hospital with video EEG capabilities that had never happened.
Taking into consideration all these facts, the patient did not require admission to the hospital at the acute inpatient level of care, based on the severity of the patient's condition and the complexity of the services provided.