Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Seizure
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is modified

This case involves a male who reportedly had seizure activity at home and was previously admitted with complaints of two seizure-like activities while playing at the playground. He was brought to the emergency department and treated with Keppra. A video electroencephalography (VEEG) did not capture any seizure activity but showed occasional theta slowing over the right temporal on day 1 and day 2, which disappeared after the electrodes were fixed. The patient was given a normal VEEG and discharged home along with Diastat. He returned for four seizure-like activities at home with no reported triggers to include fever, and negative COVID (coronavirus) testing. He was having generalized tonic-clonic activities but had a normal neurological examination. The episode started at 3:30 AM (morning) and lasted 30 seconds, with a second one at 6 AM lasting 1.5 minutes, with a third at 8 AM, and the last one at 8:30 AM lasting 30 seconds. With each episode, the patient would scream and then have whole body shaking along with a snoring sound.  The physician subsequently admitted the patient for the EEG (electroencephalography) to capture episodes, characterization, and determine the type of epilepsy. This was to help select appropriate treatment planning. He remained on inpatient status. A notice of adverse determination was received stating that the patient went to the hospital to monitor seizures. The plan clinical criteria consider a full hospital admission medically necessary when severe problems exist to include the need to stop seizure medications or when there is a need to see more seizure activity. Information provided did not show that these or other severe problems were noted. The determination was based upon the MCG (Milliman Care Guidelines), as modified by the plan, called EEG, video monitoring, pediatric (ORG: W0122).  This review pertains to the denial of coverage for an inpatient hospitalization.  

The healthcare plan acted partially reasonably and with some medical judgment and in the best interest of the patient.

According to the Milliman Care Guidelines, the patient was a candidate for 1 day inpatient stay to monitor his seizure activity, and to treat if necessary, and refer for further testing upon discharge. The records noted that the patient had more than 1 seizure in a 24-hour period and would therefore be appropriate for 1 day inpatient stay for monitoring/testing using EEG, MRI (magnetic resonance imaging), laboratory testing, etc., and to receive treatment to control the seizure activity. An MRI of the brain showed no epileptogenic focus identified. The EEG report noted abnormal findings, demonstrating generalized epileptogenic dysfunction. The seizure type was onset with screaming and bilateral motor manifestation. Given the provided information, it was determined that while a 1-day inpatient stay was supported, the rest of the hospitalization was not medically necessary. The patient could have been safely discharged after 1 day to continue treatment with his primary care physician. The physician would have the capabilities of referring the patient to appropriate specialist for further care if necessary. 

The insurer's denial of coverage for the inpatient hospitalization is modified. Medical Necessity is substantiated for admission on day 1 with discharge on day 2. Medical necessity for a continued admission was not substantiated.