Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a female. She was brought to the emergency room via EMS due to new-onset seizure. Her medical history was notable for viral meningitis, migraines, and asthma. Her parents reported she had a seizure and was shaking and unresponsive while at home. The patient reported she had come home from work reporting a headache that was different from her baseline headaches as well as light sensitivity. She took two Percocet and vomited shortly afterwards. While resting in bed, her mother noted her hands were in fists and her elbows were flexed against her body. She made grunting noises and appeared stiff and her eyes were open, "but she wasn't there." She was confused following the incident. EMS services were called.

On exam, the patient was tachycardic and complained of headache. CT scan of the head and MRI were unremarkable. Neurology was consulted. EEG (electroencephalogram) was suspicious for underlying seizure disorder. Admitting diagnosis was listed as new onset seizure without head trauma. The patient was given levetiracetam and discharged the following day with instructions to follow-up with neurology.

The patient had one seizure but subsequently was clinically stable, completely recovered in terms of alertness and consciousness. She had stable vital signs, and there was no evidence of recurrent seizures or status epilepticus or any evolving neurological deficits. The patient's brain imaging was normal as well. Practice guidelines and peer-reviewed medical literature does not support overnight admission for the cases of first unprovoked seizure. Therefore, overnight acute care admission was not medically necessary, and the patient could have been managed at a lower level of care.

Considering that the patient was stable after her seizure and did not have status epilepticus or any neurological deficits or imaging findings, did not require any ongoing intravenous treatments or surgery or other procedures, inpatient admission was not medically necessary and therefore the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.