Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient is a female with a past medical history of a gunshot wound to the head, brain surgery, and seizures.  The prehospital care report summary noted that the patient had a history of seizures and was currently on medication.  The patient's last seizure was six months before the current seizure.  The patient was noncompliant with her medication.  The patient stated that the medication made her dizzy.  The patient was alert and oriented.  The patient showed signs of abrasion on the tongue with bruising.  The patient was transported to the hospital.  At the Emergency Department (ED), it was noted that the patient had been on Keppra but had not taken it for a long time.  The patient was accidentally hit on the right side of her head with a car seat.  The patient complained of a headache and an aura for seizure.  The patient did not recall the episode.  The patient had no urinary incontinence, no nausea vomiting, or dizziness.  The seizure was witnessed by the patient's daughter.  The physical examination revealed slight tenderness to palpation on the right side of the patient's head.  The patient's manner was appropriate for the situation.  The patient was awake, alert, oriented to person, place, and time/situation.  The patient's mood was appropriate.  The patient had bit the left lateral part of her tongue.  The patient was alert and oriented and there were no focal deficits or motor or sensory deficits.  The patient was given Keppra.  The patient's computed tomography (CT) scan of the head without contrast revealed a right parietal temporal craniectomy defect with a metallic radiodensity causing streak artifact which limited the evaluation of adjacent structures.  There were 2 calcifications subjacent to the craniectomy measuring 1.0 cm and 1.2 cm.  There was a left parietal intact moist/gliosis with expected dilatation of the right posterior horn.  There was no acute intracranial hemorrhage, mass-effect, or midline shift.  There was no CT evidence of acute large territory vascular infarct.  The patient was admitted to the Medical Surgical floor.  Neurology was consulted.  The patient was to undergo neurologic checks every 6 hours and was given Depakote twice a day.  The patient was to receive intravenous (IV) Keppra every 12 hours.  The patient was subsequently discharged with instructions to keep taking the medication as ordered.

Based on the review of the medical record and literature, hospital admission was not medically necessary for this patient. This patient presented with a breakthrough seizure in the setting of medication noncompliance. The patient's exam and computed tomography (CT) scan in the Emergency Department (ED) were benign.  After resuming Keppra (levetiracetam), the patient was safe for discharge to home with outpatient follow-up.  The elevated ammonia without elevated liver transaminases could have been repeated after hydration and managed as an outpatient. The rationale for every 6 hours neuro checks is not provided.  Electrolyte trending is mentioned, but the rationale is not provided and this does not seem to have been done. 

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

The insurer's denial of coverage for the Hospital Admission is not substantiated. The insurer's denial should be upheld.