Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay. The determination is upheld.

The patient was brought to the emergency department by Emergency Medical Services (EMS) from home after he was found laying on the ground and having a seizure in front of his apartment building. Reportedly, the patient had a similar episode earlier in the year. At that time he was taken to a hospital. However, he left the hospital against medical advice and did not follow up with a physician afterwards.
According to the records, on the day of admission, the patient was initially confused, but by the time he was seen by the admitting physician he was awake, alert, and oriented times 3.
The review of systems was negative for dizziness, syncope, fatigue, chest pain, shortness of breath, vision changes, or changes in bowel or urinary habits.
When the patient was seen by the admitting physician, he was afebrile. His blood pressure was 135/90, pulse rate 67 beats per minute (bpm), respiratory rate 20, and oxygen saturation 98% on room air. The patient was a well-developed, well-nourished individual who was not in acute distress. At that time he was restless/fidgety.
He had unilateral tongue ecchymosis on the left side, also swelling, ecchymosis, and superficial skin laceration on the right side of the lower lip. The cardiovascular exam was unremarkable. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. On the neurological exam, the patient had no focal deficits. There was normal muscle strength and sensation in the upper and lower extremities.
Laboratory evaluation revealed that his white blood cell count was 16.9, hemoglobin 15.4, hematocrit 44.8, and platelets 248. The sodium was 142, potassium 4.3, chloride 106, bicarbonate 26, blood urea nitrogen (BUN) 11.0, and creatinine 0.95. Liver function tests were normal. The initial creatine phosphokinase (CPK) was 369. A computed tomography (CT) scan of the head was interpreted as a negative study. The chest x-ray was normal.
The patient was admitted to the hospital with a diagnosis of syncope to rule out cardiogenic versus neurogenic etiology, rhabdomyolysis. The admitting physician stated that upon arrival to the emergency department the patient was hemodynamically stable and euvolemic. The admitting physician also stated that the patient's electrolytes were within normal limits, and the patient had no signs of anemia.
In the hospital, the patient was seen by a neurologist who indicated that the patient was admitted with a recent onset of seizures. By history, his first episode was at least 2 months before the current presentation. Therefore, the patient was recommended treatment with Keppra.
A magnetic resonance imaging (MRI) scan of the brain was ordered but not performed while in the hospital. The patient underwent an electroencephalogram (EEG), which was interpreted as normal.
In the hospital, the patient was found to have mild rhabdomyolysis that was treated with intravenous fluids. At the time of discharge, the creatine phosphokinase (CPK) was trending down.
During the entire hospital stay, the patient remained seizure-free. He was discharged home in satisfactory clinical condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
Based on a review of the medical records, the patient had a seizure that was not associated with hemodynamic instability, status epilepticus. Based on the review of systems, physical exam, and imaging studies performed in the hospital, there was no evidence of brain disorders such as a tumor, edema, trauma, hydrocephalus, encephalitis, meningitis. The seizure was not caused by drug toxicity, withdrawal. The cardiac monitoring did not reveal cardiac arrhythmias of immediate concern. Since the time of admission, the patient remained awake and alert. There was no evidence of focal neurologic deficits, severe metabolic abnormalities, recurrent seizures.
The rhabdomyolysis was mild. At this CPK level, complications such as acute kidney injury or significant electrolyte abnormalities were unlikely. Furthermore, the mild rhabdomyolysis significantly improved after the administration of intravenous fluids.
Taking into consideration all of this information, care could have been provided at a lower level. Overall, his clinical condition remained stable and the patient did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.