Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for long-term continuous video electroencephalogram monitoring (CPT 95700) during an inpatient hospital stay (5-day hospital stay).Whittaker states that epilepsy is a clinical diagnosis based on the history of the patient and of witnesses. Whitaker states that sometimes this is not available or is incomplete, thus making diagnosis uncertain. In other cases, specifically in patients with intractable epilepsy being considered for epilepsy surgery, the diagnosis of epilepsy is not in doubt but the precise localization of the epileptogenic zone needs to be determined. Whitaker explains that in both of these situations, video telemetry plays a key role and is now a routine in most neuroscience units. A review by Whitney and Donner found that sudden unexpected death in epilepsy (SUDEP) is the most common cause of epilepsy-related death in children and adults, affecting approximately 1 in 1000 people with epilepsy each year. They noted that risk mitigation strategies include reducing seizure frequency, optimizing therapy, and the use of nocturnal supervision/seizure detection devices. Verducci and colleagues reviewed 237 definite and probable cases of SUDEP in the North American SUDEP Registry, and found that clinical risk factors included young adulthood (median age 26). They noted that 62% of decedents were male, and a sizeable minority of SUDEP occurred in patients thought to be treatment responsive or to have benign epilepsies.In this case, the patient has epilepsy, with on-going nocturnal seizures despite being on a supratherapeutic dose of levetiracetam (Keppra). The precise nature (semiology) of the patients seizures has not been established, and he has been described as having benign Rolandic epilepsy and occipital lobe epilepsy in the submitted medical records. Most, but not all, patients outgrow benign Rolandic epilepsy by their mid-teens. The patient is a young adult male with uncontrolled nocturnal seizures. This places him in the highest risk category for Sudden Unexpected Death in Epilepsy (SUDEP). Video EEG telemetry is medically necessary to capture seizures, clarify their localization and semiology, and to optimize his medical management. It is imperative that his seizure control is optimal to decrease as far as possible his risk of SUDEP. During a 5-day video EEG telemetry, if necessary, his anticonvulsant medication can safely be tapered or stopped to capture seizures while he is under close observation in a hospital. Accordingly, long-term continuous video electroencephalogram monitoring (CPT 95700) during an inpatient hospital stay (5-day hospital stay) is medically necessary to treat the patients medical condition to prevent disease, disability, and other health conditions or their progression, as the patient has uncontrolled seizures despite high dose anticonvulsant. The requested services are also medically necessary to prolong life, as the patient is at high risk of sudden unexpected death in epilepsy (SUDEP). The requested services are also medically necessary to promote the patients physical and mental health and efficiency.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's condition in order to prevent disease, disability, and other health conditions or their progression, to prolong life, and to promote the patients physical and mental health and efficiency. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same