Diagnosis: Seizure
Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial is upheld.

This patient is a female who had a repeat cesarean section and presented to the emergency department several weeks later for seizure activity. The documentation detailed in the history and physical indicates that this patient had 4 seizures in 24 hours. The patient reported headache rated at a 10/10 and denied visual disturbances. The patient denied seizure activity since the admission. The patient has been diagnosed with a seizure disorder several years prior, and was taking carbamazepine. Objectively, the history and physical noted the patient refused examination. The patient's vital signs revealed a blood pressure of 140/84, pulse of 89 bpm and oxygen saturation of 100%. The patient was recommended to undergo laboratory studies and neurology consult evaluation. The documentation indicates that prior to arrival the patient was given Valium by emergency medical services for one witnessed seizure. The patient was noted to be uncooperative during a neurology consultation, and she did not permit a full neurological examination and wanted to leave.

Based on the documentation, there were no significant abnormalities noted. The patient's speech was clear, and there was no evidence of any facial asymmetry. The patient signed out against medical advice the following day prior to completion of laboratory studies.

Based on this review of the medical record provided, this patient did not meet the Milliman Care guidelines and InteQual 2016 criteria for inpatient admission. Though the patient had an episode of seizure activity prior to arrival to the ED, there was not recurrent seizure activity noted upon arrival to the ED, and the patient was hemodynamically stable. There were no clinical indications of brain disorder, cardiac arrhythmias, new focal neurologic deficit or support that this patient's care could not be established as outpatient (e.g., patient cannot tolerate medication, initiation requires inpatient care). The patient could have been treated with appropriate anti-convulsant therapy in the ED and have the neurological consultation performed in the ED with expeditious outpatient follow-up with neurology for an outpatient electroencephalography (EEG) testing. The care that the patient received as an inpatient did not warrant the acute level of care of inpatient admission.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of the coverage for the inpatient hospital services at the acute level of care is upheld. The medical necessity is not substantiated.