Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with Down syndrome and Autism. He was admitted due to a new onset seizure. The seizure was described as generalized tonic-clonic with tongue biting and lasted about five minutes. He was taken to the emergency room (ER) where he was still post-ictal. Once in the emergency department he became more alert, and then became fully alert and oriented. His vital signs were stable.  Labs, including a complete blood count (CBC) and comprehensive metabolic panel (CMP), did not show major derangement. A head computed tomography (CT) was unremarkable. The patient was admitted for further evaluation. 

The patient underwent testing with a video electroencephalography (EEG) over two nights.  The first night, the electroencephalography (EEG) was normal. The second night, the electroencephalography (EEG) showed rare bisynchronous fronto-central sharp waves during sleep.  The patient was treated with Keppra and discharged home.  

The inpatient admission was denied by the plan due to not meeting criteria for inpatient level care. This was appealed by the treating facility with a letter stating the admission met Milliman Care Guidelines.  This review in is regards to the inpatient stay.

No, the proposed inpatient hospital admission was not medically necessary.
The admission was not medically necessary.  The patient could have been safely and effectively managed at a lower  level of care. Based on published guidelines and standard of care, new onset seizures should be evaluated promptly with neuroimaging and electroencephalography (EEG). Based on the literature and standards of care, admission to inpatient level care is indicated when there are higher risk situations.  Examples include, if there are two or more seizures on the day of admission, recurrent seizures, preventative anticonvulsant treatment is needed and evaluation with an electroencephalography (EEG) is required. In addition, other situations where inpatient admission is required includes patients with new onset seizures at age less than one year old, status epilepticus (seizure greater than 15 minutes), prolonged alteration of mental status, unexplained focal neurological deficits on exam, need for multiple doses of benzodiazepines to abort seizures, continued maintenance intravenous anticonvulsant treatment for seizures and intravenous treatment for major metabolic derangement.  Patients with less acute presentations of new onset seizures can generally be cared for in lower levels of care. 

In this case, the patient had a single self resolving seizure and recovered mental status while in the emergency department.  The patient did not have multiple seizures, status epilepticus, focal neurological abnormalities on examination, and was described as generally stable at the time of admission.  The patient remained stable during the admission without complications.  The intensity of testing, which primarily included long term video electroencephalography (EEG), did not require inpatient level care, as it can also be completed in at a lower level of care. Thus, the patient was not acutely ill enough or had high enough risk of decompensation to require inpatient care. Therefore, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Patients with new onset seizures require prompt evaluation. Some cases with high acuity (status epilepticus, multiple seizures on day of presentation, new neurological deficits, severe metabolic derangement, and others) require inpatient level care (Sartori, Sansevere, Goldberg).  Patients with less complicated presentations and lower levels of acuity can be managed in lower levels of care.  In this case, as discussed above, the patient had a single seizure and was clinically stable at the time of admission.  The patient's presentation did not support care at admission level. Thus, the plan denial of the inpatient level of care was reasonable and with sound medical judgement and in the best interest of the patient, because the patient could have received prompt care in a lower level of care.