Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient hospital stay
The denial is: Upheld in whole

The patient is a female with a past medical history significant for a seizure disorder, autism, and slow mentation, who presented to the emergency department after she had four episodes of seizures at home. The initial episode lasted for approximately one minute. The subsequent episodes lasted for approximately 30 seconds each. The fifth episode occurred in the emergency department. Reportedly, the patient had breakthrough seizures in the past, and they were associated with her menstrual cycle.

Computed tomography (CT) scan of the head demonstrated no acute intracranial findings.

The patient was admitted to the hospital with a diagnosis of multiple breakthrough seizures. The neurology service was consulted for adjustment of the patient's home regimen. Seizure precaution measures were initiated. Reportedly, the neurologist on staff did not see the patient during the hospitalization. Instead, the patient's private neurologist was contacted, and it was recommended to keep the same regimen of antiepileptic drugs. It was suggested that the patient's seizures were provoked by the menstrual cycle.

Reportedly, on the day of discharge, the patient was in stable clinical condition. During the short period of hospitalization, the patient remained seizure-free. She was discharged home with a recommendation to follow up with her private neurologist as an outpatient. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

The inpatient was not medically necessary for this patient.
It was indicated that upon presentation to the emergency department the patient was initially somewhat confused but later became awake, alert, and oriented times 3.

It was also indicated in the note written by the emergency department provider that on the neuro exam the patient was alert and oriented, had no focal deficits, and no motor or sensory deficits.
This patient had an established diagnosis of seizures. Despite treatment, the breakthrough seizures were triggered by her menstrual cycle, which is what happened this time.

Overall, during the hospital stay, this patient remained afebrile and hemodynamically stable. There were no significant neurologic deficits documented during the hospital stay. There was no evidence that the patient's seizures were related to significant infection such as encephalitis or meningitis. There was no history or clinical signs of a head injury before these seizures occurred.

The review of the medical records clearly demonstrated that the patient had no significant electrolyte abnormalities that could trigger seizures.
There were no significant structural abnormalities contributing to the seizures that were detected by the CT scan of the head.
Overall, the patient's admission was very short, and her private neurologist did not want to make any changes to the regimen of the antiepileptic drugs.

Considering the fact that the patient had several breakthrough seizures, it was appropriate to monitor the patient closely, however this did not require an inpatient stay and the patient could have been managed at a lower level of care status.