Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure-Like Activity

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld.

This case involves a patient who presented to the emergency room with seizure-like activity.  The patient had a history of questionable absence seizures.  At school, the patient seemed to be trembling while standing in line.  The patient's physical exam findings were completely normal.  It was discussed that the symptoms may be consistent with a tic disorder versus seizure disorder.  Neurology was consulted.  It was recommended that the patient be admitted for laboratory testing and further evaluation to rule out seizures.  Magnetic resonance imaging of the brain revealed no significant findings.  A video electroencephalogram revealed generalized irregular spike and wave at 3 to 5 Hertz (Hz).  The patient was started on Keppra every 12 hours.  The electroencephalogram improved.  The patient was discharged.

The patient had a pending plan for outpatient neurological work-up.  The treating physician's clinical impression was emergent concern for seizure disorder.  Given the patient's irregular epileptiform activity concerning for juvenile myoclonic epilepsy, the patient required initiation of antiepileptic medication with Keppra and continued monitoring.  The care that the patient received could not have safely been performed on an outpatient basis.  The patient was considered high risk for clinical complications including recurrent, uncontrolled seizures, status epilepticus, acute encephalopathy, acute and/or permanent focal neurological dysfunction, arrhythmia, and death.  InterQual Guidelines and Milliman Care Guidelines (MCG) were cited.   

Per the cited sources, admission for patients with seizures is indicated for hemodynamic instability, complex febrile seizures, status epilepticus or repetitive seizures not controlled with emergent treatment, for brain disorders that require monitoring or intervention only availability inpatient level of care, for altered mental status that is severe or persistent, for new focal neurological deficits, for metabolic disorder that is persistent despite observation level of treatment, for recurrent seizures that occurred during emergency department or observation care, and when outpatient anti-seizure regimen cannot be established.  In this case, the patient presented to the hospital with reports of seizure-like activity.  The patient had a history of questionable absence seizures. 

The documentation did not identify hemodynamic instability.  The documentation did not identify that the patient had recurrent seizures occurring in the emergency department or observation care that could not be managed at the observation care level.  The documentation did not identify pulmonary, metabolic, or neurological reasons that would warrant the inpatient level of care over observation level of care.  As such, the inpatient hospital stay was not medically necessary.  Therefore, the denial of coverage for the inpatient hospital stay was appropriate and is upheld.     

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital stay is upheld.  Medical necessity is not substantiated.