Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures. 
Treatment: Inpatient emergency admission.

The insurer denied coverage for the inpatient emergency admission.  The denial is upheld. 

This is a female patient with a past medical history of immunocompromised status and seizures.  She was in the emergency department with complaints of 2 seizures.  The patient reported having an altercation when she had a loss of consciousness and had convulsions witnessed by friends who were able to hold her up and keep her from hitting her head.  Before the patient came back to baseline, she reported having a second seizure.  In the emergency department she had no new complaints and felt well.  She reported she was compliant with home medication of Keppra 1000 milligrams (mg) twice a day.  The laboratory studies revealed a Keppra level of 3.1, which was low.  She had a blood-alcohol level of 80-99 mg / 100 milliliters (mL).  The physical examination was normal.  The electrocardiogram (ECG) was normal sinus rhythm.  The patient was admitted in guarded condition for further treatment and monitoring.

According to the New York State Insurance Law Section 4900(c) regarding the conditions requiring immediate medical attention: This patient did meet criteria for point number "1: Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition." The patient had 2 seizures and so required immediate medical attention. The patient, however, did not require an escalated level of care.

According to the guidelines provided by the InterQual 2019, this acuity of this case is considered to have required observation as the patient was a known alcoholic with a breakthrough seizure due to potential intoxication and/or medication poor compliance. Upon arrival the patient was not considered to be in status epilepticus. The patient did receive 1 dose of medication to ensure no further seizures then was observed overnight to ensure no recurrence. No other interventions were necessary. The patient was described as interactive and was able to be discharged after almost 2 days. 

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with a seizure in the setting of potential intoxication and/or poor medication compliance, her symptoms did not recur after treatment with Keppra and Ativan. 

The submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient did continue to slowly improve and was discharged. The requested inpatient admission would not be the most appropriate level of care and therefore the health plan acted reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for the inpatient emergency admission is not substantiated.  The insurer's denial is upheld.