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.

The patient is a male with a past medical history significant for seizures not on antiepileptic drugs, polysubstance abuse including alcohol abuse, and hypertension who presented to the emergency department two days after he had a seizure. The patient said that he had been sitting at the computer and drinking coffee. The next thing he remembered was Emergency Medical Services (EMS) around him. His uncle witnessed the event when the patient suddenly begin shaking all over and foaming at the mouth for several minutes. He remained sitting and did not fall or experience a head injury.
The patient came to the emergency department due to persistent muscle aches and mild back pain. The pain was primarily located in the thoracic spine and was exacerbated by a change in position. His seizures were relatively infrequent. The previous seizure occurred approximately six years before his presentation following a night of drinking. The review of systems was negative for fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, palpitations, cough, diaphoresis, vision changes, sore throat, abdominal pain, or any other symptoms. Vital signs included a temperature of 36.8C., a blood pressure of 135/95 millimeters of mercury (mmHg), a heart rate of 69 beats per minute (bpm), a respiratory rate of 18/minute , and an oxygen saturation of 100% on room air.
On the physical exam, the patient was in no acute distress. He was awake, alert, and oriented times three. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound.

At issue is the medical necessity of the inpatient stay.

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

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
At the time of the initial evaluation, the patient was awake and alert. He was hemodynamically stable, had no signs of a central nervous system (CNS) infection. There was no evidence that he had focal neurologic signs. His seizure occurred two days before the presentation, and since that time the patient was seizure-free.
Reportedly, the patient totally recovered from the seizure by the time he was seen by the admitting physician, and the imaging studies did not show any acute abnormalities that required intervention. There was no evidence that the seizures were associated with significant electrolyte abnormalities. There was no evidence that the patient had any unstable concomitant conditions that would necessitate admission at the acute inpatient level of care. The rhabdomyolysis that was present at the time of admission was relatively mild. In fact, after initiation of the intravenous fluids, the creatine phosphokinase (CPK) level started to trend down very quickly. The rhabdomyolysis was not associated with acute kidney injury. There were no symptoms of active substance withdrawal.