Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Loss of consciousness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male.  The patient was brought by ambulance to the emergency department after losing consciousness; he fell and struck his head on a stove. Per his family, his eyes rolled up into his head and he was shaking. This event lasted approximately ten minutes. Afterward, the patient complained of pain to the right side of his head and he was disoriented.  The patient also reported a similar episode occurred in May and workup was negative at that time; he did not follow-up with neurology as had been recommended.   

While in the emergency room, the patient had a flat affect, fogginess, and short-term memory deficits. Computed tomography (CT) scan of the head and cervical spine were unremarkable. Lab work was positive for tetrahydrocannabinol (THC) (the patient admitted to marijuana use).  Neurology was consulted and recommended a loading dose of Keppra. He was also treated with intravenous (IV) saline.  It was also recommended he be admitted for diagnostic workup and further management due to concerns of possible complex seizure.   

While in the hospital, the patient reported he had infrequent episodes which involved feeling like he was going to pass out. He was admitted to the pediatric telemetry unit with a diagnosis of new onset seizure. intravenous (IV) hydration was continued. Magnetic resonance image (MRI) of the brain was unremarkable.  Electroencephalography (EEG) was normal with no electrographic seizures detected. 

During the patient's is stay, no further seizure activity was observed. Diagnosis was listed as recurrent seizures times two, possible epilepsy. The patient was instructed not to drive and was cleared for discharge the following day. He was to remain on Keppra 500 milligrams (mg) twice a day and follow-up in one week.

No, the proposed treatment was not medically necessary. 

In general, medically necessary services are those that a medical practitioner would provide a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. The services must be in accordance with generally accepted standards of medical practice and clinically appropriate and not performed primarily for the convenience of the patient or physician.
In this patient's case, there was a differential diagnosis between seizures versus nonepileptic events such as fainting. These differential diagnoses could have been addressed by outpatient routine electroencephalography (EEG), or a routine electroencephalography in the emergency room, or ambulatory electroencephalography for 24-48 hours on an outpatient basis. These above-stated tests are standard of care and would be expected to produce equivalent results as video electroencephalography, without any need for in hospital admission. Considering that there is an alternative service at least as likely to produce equivalent results, inpatient hospital admission was not medically necessary.  Standard of care is to treat at the lowest level appropriate for that patient's care.

The treating providers have a variety of options of evaluating this patient without resorting to inpatient admission. The patient was clinically and neurologically stable, had a non-focal new exam and normal brain imaging. The testing for seizures could have been performed in a different format, as indicated above, with equivalent results (references 1-3)