Appeal type: Medical necessity
Decision: Upheld

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

This case involves a patient who presented to the emergency department with new onset of seizures and was subsequently admitted for inpatient care. Records noted that the patient was denied coverage for the inpatient stay with claims that he could have been kept in observation with negative tests and improved symptoms and discharge for observation with an ambulatory plan of care. 

The Milliman Care Guidelines have noted that inpatient admission for patients with seizures are indicated when the patient has 1 more the following to include hemodynamic instability, status epilepticus, a brain disorder that requires monitoring or intervention available only at an inpatient level of care, with the etiology requires monitoring or intervention available only at inpatient level of care or that persists despite observation care. If the patient has altered mental status that is severe or persistent, has no focal neurologic deficit post seizure, has a metabolic disorder that persist despite observation care, when there is recurrent seizure activity and 1 of more the following occurs to include that the patient did not know to have had a seizure disorder, has recurrent seizure of a different type than previously known, the patient with baseline of infrequent seizures and recurrence not thought to be due to readily modifiable etiology. Inpatient care may also be indicated when outpatient antiepileptic regimen cannot be established, when there is a need for cerebral bleeding, hydrocephalus, or vasospasm monitoring, and when there is increased intracranial pressure or cerebral edema monitoring.

In the case of this patient, the information stated that the patient was observed to be making a "grunting sound", rolled off the bed, and had a tonic-clonic seizure lasting approximately 1-2 minutes. He had no history of recent trauma or illness but reported a mild headache occurring off and on in the past. Upon arrival to the emergency department, his blood pressure was 160/89. He underwent laboratory studies including urine toxicology, EKG (electrocardiogram), chest x-ray, and CT (computed tomography) of the brain. He was given intravenous Keppra 1500 mg (milligrams) along with intravenous Ativan.  Records indicated that it was difficult to determine the cause and there was concern for recurrent seizures. His CT of the brain was negative. Laboratory test results were normal other than slight elevation in MCH (macrocytic anemia) at 34.0. The patient was subsequently admitted for further evaluation and management. An appeal letter indicated that the patient required not only an expeditious evaluation as to the cause of his seizure, but skilled assessment of his vital signs, telemetry monitoring, neurological status, laboratory and diagnostic testing, and assessment for any signs of clinical deterioration. However, the presenting evidence did not support that the patient cannot have undergone the same treatment and diagnostic testing on an observational basis that he received on inpatient care. He did not have any recurrent seizures and while further work-up was standard of care, the information did not support the need for inpatient level of care the same services could have been rendered on a lower level. The inpatient care was not medically necessary. As such, in accordance with the previous denial, the denial of coverage for inpatient admission is upheld.

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

The insurer's denial of coverage for inpatient admission upheld. Medical Necessity is not substantiated.