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

The patient is a woman with a history of hypertension, traumatic brain injury and seizure disorder who presented to the hospital with a chief complaint of being found down on the floor at her apartment. Emergency medical services had previously seen the patient multiple times for frequent falls. She reported that she was drinking alcohol earlier and then fell down the stairs. There was also concerned for loss of continence that may have been seizure related.

The inpatient hospital care was medically necessary for this patient. She presented with suspected seizures, acute rib fractures, acute fall, and acute alcohol intoxication. Overall, she was at an increased risk of an adverse outcome due to each of these comorbid complications. The patient did leave the hospital against medical advice, but this did not relate to the appropriateness of admitting her to the hospital. Patients with seizures and a history of alcohol abuse may experience recurrent seizures in the setting of non-adherence to neuroleptic medications. Inpatient hospital care is appropriate for a patient with this type of presentation.