Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Full Inpatient Hospital Admission for vEEG (video electroencephalography)
The insurer denied the Full Inpatient Hospital Admission for vEEG (video electroencephalography).
The denial is overturned. 

The patient is a male with longstanding history of obstructive sleep apnea as well as epilepsy. He was seen in the emergency department  due to breakthrough seizures after having a witnessed seizure during which he was gasping and continued to jerk after the seizure. The patient had multiple seizures despite being compliant with Keppra.

The patient's pediatric neurologist saw the patient in follow-up via telemedicine. It was noted that EEG (electroencephalogram) done was mildly abnormal and suggestive of right-sided cortical irritability. Medications included pyridoxine, Keppra, vitamin D3, Flonase, and diazepam. Medication adjustments were made.

The patient's mother had concerns regarding the patient gasping during his seizures and if he would still be able to undergo tonsillectomy and adenoidectomy (T&A). The neurologist noted that with increased doses of Keppra, the patient should have better coverage. However, in order to evaluate the patient's readiness to undergo surgery, the neurologist recommended that the patient undergo inpatient video EEG (electroencephalogram) monitoring during sleep in order to fully witness and treat the patient's nighttime seizures. The patient's ENT (otolaryngology) surgeon would not perform the planned T&A (tonsillectomy and adenoidectomy) surgery until his seizures are proven to be under good control. According to the provider, the patient will require a 48 to 72 hour test, and medication adjustments, including initiation of new medications, during the admission.

Yes, the Full Inpatient Hospital Admission for vEEG (video electroencephalography) is medically necessary.

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. They 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 addition, they cannot be more costly than an alternative service at least as likely to produce equivalent results.

The patient has epilepsy with breakthrough seizures, not responding to the current treatment, and comorbid obstructive sleep apnea. According to the provider, a prolonged study up to 48 hours to 72 hours is required, with adjustment of medications and initiation of new medications. Considering that the study required is prolonged, and considering that medication adjustments and related observation is needed, such study cannot be performed on lower level of care status basis. Therefore, inpatient admission is within the generally accepted standards of medical practice, clinical appropriate, is not for convenience of the patient or physician, and, as such, is medically necessary.

The patient has epilepsy that is not controlled on the current medication schedule. Video EEG (electroencephalogram) was requested to capture seizures, diagnose the problem, and adjust medications. The provider estimates 48 to 72 hours to complete this task. Due to medication adjustments and prolonged study, it cannot be completed on outpatient basis or observation status basis, and therefore inpatient admission is medically necessary.