Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a patient with a history of epilepsy.  Emergency department note indicates the patient had chief complaint of chest pain, dizziness, and headache since that morning status post seizure yesterday.  The patient had a past medical history of epilepsy and was on medication management.  Physical examination revealed 98% (percent) oxygen saturation, blood pressure of 123/79, with strength and sensation grossly intact.  Heart rate was noted at 101 beats per minute (bpm) on physical examination but at 99 under vital signs.  The patient was recommended for a head computed tomography (CT) and labs given breakthrough seizures and symptomatic headaches.  Chest x-ray revealed no acute findings.  CT scan of the head/brain revealed no evidence of acute territorial infarct or intracranial hemorrhage.  The patient was noted to have elevated prolactin suggestive of seizures.  The patient was treated with Keppra and admitted for work-up for breakthrough seizures in the presence of epilepsy and negative COVID (coronavirus).

Admission reported the patient had breakthrough seizures yesterday and today and was feeling unwell with headache.  Heart rate was 73 on exam.  Prior diagnostics were reviewed.  The patient was recommended for continuation of intravenous (IV) Keppra and neurology consult in the morning.  Electroencephalogram (EEG) was ordered.  It was noted that the patient did not take her antiepileptic medications that day and had been taking valerian root for sleep.

Progress note reported the patient had no acute issues overnight and felt well.  The patient reported recent stressors about the situation in her native country and had not been able to sleep recently.  The patient was recently started on antibiotics for Helicobacter pylori (H. pylori) 5 days ago and had been suffering from migraines recently.  The patient was recommended for neurology consult and EEG.  The patient had no seizures overnight but was recommended for seizure precautions.

Neurology noted the patient had mild headache and otherwise felt at her baseline.  The patient denied any overnight events.  The patient was noted to have no gross focal deficits on neurological exam.  The patient was diagnosed with breakthrough seizures likely due to seizure threshold lowering effect by antibiotics given for H. pylori.  The patient was recommended for medication management and awaiting video EEG results.

The inpatient hospital admission was not considered medically necessary for this patient.  The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

Milliman Care Guidelines (MCG) recommends inpatient admission when the patient is hemodynamically unstable, there is a need for monitoring or intervention available only at inpatient level of care or that persists despite observation care, there is cardiac arrhythmias of immediate concern, there is severe altered mental status, there is a new focal neurological deficit, and/or a metabolic disorder that persists despite observation care.  Admission for recurrent seizures is recommended if seizure occurs during emergency department or observation care and the patient is not known to have a seizure disorder or recurrent seizure is of a different seizure type than previously known seizure disorder. 

The patient was noted to have seizures.  However, no seizure occurred after presentation to emergency room.  The patient also reported taking antibiotics for infection, supplements for sleep, and not taking her anti-epileptic drugs (AED).  Monitoring and treatment could have occurred at a lower level of care such as observation, as recurrence was due to readily modifiable etiology (medications).  Inpatient admission was not medically necessary.  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 inpatient hospital admission is upheld.  Medical necessity is not substantiated.