Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
According to the documentation submitted, this is the case of a patient with a history of schizophrenia and post-traumatic stress disorder. She presented to the emergency department for falls, possible seizures, dizziness, and suicidal thoughts. She was admitted the same day. She received diagnostic imaging, laboratory work, one to one observation due to a risk for self-harm, intravenous medications, a neurology consultation, a rehabilitation consultation, and a psychiatry consultation.  The patient complained of vertigo, dizziness and walking instability. On examination it was noted that the patient was well oriented and had normal strength and sensation. In the impression it was noted the seizures versus mechanical falls. The plan was to obtain a computerized tomography (CT) scan head and psychiatric consult.  The patient was seen for psychiatric consult. He noted that the patient had history of intellectual disability, schizophrenia, and post-traumatic stress disorder (PTSD). The primary psychiatric diagnoses were intellectual disability and schizophrenia. He noted that the plan was to start the patient on Clozaril.  Head CT showed mild cortical atrophy and small vessel change but no acute finding.

There was a discharge summary which noted the discharge diagnoses of seizure, frequent falls, suicidal ideations, constipation, diarrhea and syncope. It was noted that the patient complained of feeling dizzy and had room spinning sensation as well as convulsions on the floor with hitting her leg and back. It was noted that the patient had a similar episode six weeks earlier. The MRI (magnetic resonance image) of the brain and EEG (electroencephalography) were unremarkable.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. The patient's admission diagnosis was new onset vertigo versus fall related to seizures. Admission for further workup was medically necessary and recognized as criteria for admission.

Inpatient admission is considered medically necessary for this patient. The patient's admission diagnosis was new onset vertigo versus fall related to seizures. Admission for further workup was medically necessary and recognized as criteria for admission.

"All patients with a first seizure presentation should be investigated with routine blood tests to exclude infection or metabolic disturbance and should have an electrocardiogram (ECG). The majority of uncomplicated first seizure patients do not require urgent brain imaging before discharge. MRI is the imaging modality of choice to investigate seizures and will be organized via a first seizure clinic. Urgent brain imaging (preferably with MRI, but with computed tomography [CT] if MRI is not available / feasible acutely) before discharge should be considered in those patients where an acute intracranial event is suspected." (Galizia, E. C., & Faulkner, H. J. 2018).
The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.