Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission. 
The insurer's denial should be upheld.

This case involves a female with history of diabetes, schizophrenia and depression who presented to the Emergency Department (ED) with seizure-like activity.  The patient's relative indicated that the patient was complaining of feeling weak all day and then, he witnessed the patient's seizure lasting approximately 3 minutes.  The patient was discharged a few days prior for depression and during the admission she had an episode of hypoglycemia.  The patient did not have any history of seizure. However, the patient was noted to be noncompliant with her insulin and oral anti-hyperglycemic medications over the past few days since her discharge. In the ED, the patient's oxygen saturation was 100% on room air, and the patient was oriented to person, place and time and was in no acute distress.  The documentation indicated that the patient's clinical presentation was concerning for intracranial pathology, as well as seizure secondary to toxicologic cause versus metabolic derangement. This patient's psychiatric history was significant for prior suicidal attempts. Once stable it was noted that the patient was recommended for discharge.  The patient was discharged with instruction to follow-up.

According to clinical guidelines, admission is indicated for seizure if one or more of the following is documented: Hemodynamic instability, status epilepticus or repetitive seizures not controlled with emergent treatment; brain disorder (e.g., tumor, edema, trauma, hydrocephalus, encephalitis, meningitis) that requires monitoring or intervention available only at inpatient level of care; etiology (e.g., drug toxicity, withdrawal, nonadherence) that requires monitoring or intervention available only at inpatient level of care or that persists despite observation care... In this case, this patient did not have any of the above.

According to clinical guidelines, admission is indicated for hyperglycemia when there is one or more of the following: hemodynamic instability; altered mental status that is severe or persistent; dehydration that is severe or persistent; vomiting that is severe or persistent; significant electrolyte abnormality (e.g., hypokalemia, hyperkalemia, hypernatremia) that persists despite observation care treatment; glucose level persistently too high for next level of care (e.g., concern for redevelopment of dehydration, electrolyte abnormality) In this case, this patient's hyperglycemia could have been stabilized in the ED or in the observation level of care and discharged with outpatient follow-up. 

Based on the review of the medical records, this patient presented to the Emergency Department (ED) with seizure-like activity. However, the suspicion for seizure was low based on the clinical workup. However, the patient's history was concerning for toxic overdose versus altered mental status secondary to hyperglycemia. The patient had diabetes, was noncompliant with her insulin regimen, and had a glucose reading of 438 in the ED. The patient also had a significant psychiatric history that included depression, schizophrenia, and suicidal attempts in the past. The patient could have been admitted to observation level of care if there was concern for this patient's safety and another seizure-like activity. The psychiatry and neurology consult with electroencephalogram (EEG) study could have been provided in the observation level of care.

Based on literature review, inpatient admission was not medically necessary to treat this patient's medical condition. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.