Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This case a patient who presented to the emergency department on for possible seizure.  The patient had a history of type 2 diabetes mellitus without complications and reported cannabis use.  In triage, the patient claimed to have suffered two seizures 2 days prior and was seen at a different facility the day before but left against medical advice (AMA).  The patient was being seen for a video electroencephalography (EEG) and reported no seizure activity since the initial episode. The patient's blood pressure was 117/63 with a heart rate of 102.  Respiration rate was 18 with temperature 96.6 and pulse oximetry at 100% (percent) on room air.  The patient had a body mass index (BMI) of 20.9 and denied any pain. The patient was alert and oriented with a Glasgow coma score (GCS) of 15. The report stated the patient had a witnessed seizure by his girlfriend the morning prior. The patient reported smoking marijuana daily but denied any other drug use or alcohol use. The patient left the other facility the day prior as there was no bed available. The patient's physical examination was unremarkable. The patient stated that the other facility recommended the patient be admitted for the EEG. The patient left AMA prior to the EEG claiming that they were unhappy waiting for transport.  The encounter note stated the patient sustained a tongue laceration the day prior but had no seizure activity since.  The tongue laceration was healing.  The plan of care included admitting the patient for further evaluation.  The history and physical note stated that the patient has controlled diabetes mellitus and per the patient's girlfriend (who witnessed the seizure event), the patient went to bed early the night before because of a headache. Around 5 AM, he grabbed her strongly and his whole body began shaking. The patient's girlfriend claimed that the patient's eyes rolled back, and was foaming from the mouth. The episode lasted approximately 2 minutes whereupon the patient's girlfriend called emergency medical services, and the patient was brought to another emergency room facility whereupon they left AMA to come to the current facility. The patient admitted to poor sleep patterns, sometimes staying up all night to play video games. The patient also had a history of opiate abuse but denied any use since the patient was incarcerated previously. The patient denied any benzodiazepine or alcohol abuse and only drinks alcohol socially. The patient denied any prior history of seizures but did admit to having a first cousin with a seizure disorder.  A computed tomography (CT) of the head showed no evidence of acute intracranial pathology. The patient was denied coverage for the inpatient stay given that the work-up was unremarkable, the patient was hemodynamically stable, and neurologically intact.  The plan was to admit the member for further neurology and epilepsy work-up.  The patient left AMA on the same day they were admitted.  During the brief hospitalization, which lasted approximately less than 24 hours, the patient had no medical conditions with clinical characteristics that met InterQual criteria for inpatient level of care.  An appeal was submitted claiming that the patient had 2 witnessed seizures, was lethargic, and had an elevated heart rate.  The patient was admitted to the Medical/Surgical unit with a seizure and placed on seizure precautions. The plan of care consisted of video electroencephalogram monitoring, frequent neurological assessments, hemodynamic monitoring, glucose monitoring, and serial lab work.  


Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.