Diagnosis: Seizure.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a man with a history of asthma, seizures and alcohol abuse who presented to the hospital. He presented with a chief complaint of a seizure. He reported last drinking on the prior day. After losing consciousness, he awoke laying on the floor. He denied shortness of breath, nausea, vomiting and diarrhea. He reported drinking 2 pints of vodka daily. Vital signs showed blood pressure 153/78, heart rate 102, and temperature 98.3 Fahrenheit. On physical examination, there were tongue fasciculations and tremors. Heart was regular and abdomen was soft and nontender. There was no cranial nerve deficit reported. Labs showed white blood cell (WBC) 4.65, hemoglobin 12.5, creatinine 0.69, sodium 132, and potassium 3.8. Alanine aminotransferase (ALT) was 204, aspartate aminotransferase 280, alcohol level was negative, and lactate 8.8. Head computed tomography (CT) was negative for acute abnormalities. CT of the cervical spine was negative for fractures. The patient was admitted for alcohol withdrawal with seizure. The plan of care included telemetry, Neuro checks, Clinical Institute Withdrawal Assessment (CIWA) protocol, benzodiazepines, thiamine, multivitamin, folic acid, intravenous (IV) fluids, trend lactate, and monitor electrolytes.

The inpatient care was medically necessary. The reason is that the patient presented with seizure in the setting of suspected alcohol withdrawal. While it is correct that he had an unremarkable hospital course and responded to benzodiazepines, IV fluids, and multivitamins, his history of alcohol abuse and presenting symptom of a seizure in the setting of withdrawal increased his risk of a serious adverse outcome, such as delirium tremens. It would not be appropriate to manage a patient at this degree of increased risk at a lower level of care. The patient was at increased risk for recurrent seizures, other symptoms of acute alcohol withdrawal, development of infection and sepsis, and transfer to the Intensive Care Unit (ICU). Monitoring him more closely with Neuro checks and telemetry, while maintaining him on a CIWA, was appropriate and required an increased intensity of care given his presenting seizure.