Diagnosis: Tonic-clonic seizure

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is overturned.

This male patient has a history of neurofibromatosis.

With a history of neurofibromatosis, there is increased risk of having tumors in the brain. This may not have been seen on computed tomography (CT) done in emergency room (ER). He would need magnetic resonance imaging (MRI) with contrast.

The fact that he had a second witnessed seizure in the ER puts him at a very high risk for recurrent seizure. In addition, they had given him Ativan, which would have made him very drowsy with recurrent seizure. The first 24 hours are very crucial, and they need to be observed in the hospital.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The carrier's denial of coverage for inpatient stay is overturned. The medical necessity is substantiated.