Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a male with a past medical history of HCV and chronic back pain.  The patient was brought to the emergency room by emergency medical services (EMS).  The patient had an initial Glasgow Coma Scale (GCS) score of 8 at the scene.  The patient arrived with a GCS of 15.  The patient was standing outside the methadone clinic with his friends when he fell and hit his head.  The patient then had a seizure per EMS.  The patient was given Narcan in the field; the patient denied drug use and alcohol abuse.  The patient's vital signs in the emergency department included blood pressure 102/56, a heart rate of 65 and a respiratory rate of 18.  The patient indicated he had similar episodes in the past.  The patient underwent computerized tomography of his head and chest, which were negative.  The patient was treated with intravenous fluids and was admitted with seizure precautions.  The patient underwent an echocardiogram, which was normal. The patient underwent a Holter monitor test which revealed an underlying rhythm of normal sinus rhythm with supraventricular ectopic (SVE) beats.  The patient underwent a myocardial stress test which revealed mild inferior wall ischemia with no significant perfusion defects.  The calculated left ejection fraction was normal.  The patient was stabilized and discharged.

The health plan did act reasonably and with sound medical judgment and in the best interest of the patient.

According to Foster, et al (2018) article, majority of the community-onset seizure group had no identifiable acute provoking factor but had higher rates of remote seizures risk factors, such as cerebral lesions (structural brain damage or cerebral cancers). However, this patient's CT of the brain showed no acute intracranial pathology. With this possible unprovoked epileptic seizure, Visoso-Franco et al (2019) article suggests that the diagnosis is confirmed with either EEG or VEEG; and all of these can be done at the ED setting. 

Sandhu and Sheldon (2019) article on "Syncope in the Emergency Department" indicates that the risk stratification performed in the ED is important for estimating prognosis, triage decisions and to establish urgency of any further work-up. And following risk stratification, decision for hospitalization should be based on the seriousness of the underlying cause for syncope or based on high-risk features, or the severity of co-morbidities. For those deemed intermediate risk, this article suggest that access to specialist assessment and related testing may occur in a syncope unit in the emergency department, or as an outpatient. Based on this patient's clinical picture, patient is hemodynamically stable, asymptomatic and had no compelling lab results that required urgent inpatient work-up and evaluation.

The inpatient hospital admission is not medically necessary for this patient. The patient was admitted to the hospital following a seizure. On arrival in the emergency room, his mental status was normal. A GCS was 15. The member had no recurrent seizures. He did not have abnormal imaging of the head. The patient did not have any significant laboratory or EKG abnormalities. An acute inpatient admission is not medically necessary for a seizure with return to baseline mental status and no further seizures. Without a focal neurologic deficit or other acute abnormality on imaging or laboratory studies, these patients can typically be discharged with outpatient follow-up. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.