Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient Hospital.
The health plan denied the inpatient hospital stay. 
The health plan's determination is upheld in whole.

This is the case of a female with a past medical history of chronic kidney disease on dialysis, diabetes mellitus, hypertension, cerebrovascular accident with residual weakness, dementia, and seizure disorder on Keppra, who presented to the emergency department(ED) with an episode of shaking and her lips turning blue and followed by a half hour of confusion. The patient had notably had multiple similar episodes previously with a negative work-up.
The patient was brought into the hospital with concerns for syncope with suspected neurologic etiology, such as seizure and with plans for a magnetic resonance imaging (MRI) and a magnetic resonance angiography (MRA) of the brain, echocardiogram, urinalysis, telemetry, neurology consultation, and neurologic checks.
The patient remained hemodynamically stable without recurrent events. Neurology saw the patient with an assessment that she had syncope and a history of seizures. The MRI of the brain showed evidence of multiple old infarcts without a new infarct or hemorrhage and the MRA showed no evidence of significant vessel occlusion. The electroencephalogram (EEG) demonstrated evidence of slowing without seizure activity. She was subsequently discharged on her usual dose of Keppra and off Lexapro, given it could lower the seizure threshold.
The issue in question is whether care at the inpatient level of care was medically necessary for the dates of service.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. As previously noted, this patient presented with altered mental status that improved quickly without recurrent syncope, seizure activity, significant lab or imaging abnormalities was safe to treat in observation with neurologic checks, imaging, and monitoring for further seizures and syncopal activity. Inpatient level of care was not medically necessary.
This patient presented after an episode of shaking, cyanosis of her lips and a half hour episode of confusion in the setting of having had several similar episodes previously with an unremarkable work-up. She was hemodynamically stable on presentation with confusion with that improved rapidly, mild leukocytosis, and a mildly elevated troponin, but she was not noted to have new focal neurologic deficits, evidence of acute coronary syndrome, arrhythmias, or acute abnormalities on computerized tomography (CT) of the head. She was subsequently brought into the hospital after which she had no further episodes of syncope or seizures and she had no new neurologic or other acute issues. This patient was certainly appropriate to bring into the hospital for observation, syncope work-up, monitoring for seizures, and changes in neurologic status, but in the absence of ongoing persistent acute confusion, new neurologic deficits, recurrent syncope or seizures, or significant lab abnormalities, it is unclear why she could not have been safely treated in observation. Inpatient level of care was not medically necessary and observation services were appropriate.