Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary.
The health plan's determination is upheld.

The patient is a female who had presented to the hospital for an evaluation of seizures. The patient had a prior history of a seizure disorder and averaged 1 seizure/month at baseline. Her history was also notable for hypertension and a genetic deformity to her right hand and foot. On the day of presentation, per the emergency department (ED) attending's note the patient had experienced 3 seizures. The patient was noted to have been treated with Divalproex sodium as an outpatient. The patient denied medication non-compliance. In the ED the initial neurological exam was non-focal. Labs were drawn and her valproic acid level was 34 [therapeutic range is 50-100 micrograms (mcg)/milliliter (mL)]. A decision was made to transfer the patient to the floor for further evaluation.
On the floor the patient was seen by neurology. The patient's subtherapeutic valproic acid level was noted. The patient's neurological exam was otherwise unremarkable. Neurology recommended increasing the patient's dose of valproic acid to 500 milligrams (mg) twice daily (BID) (from 250mg BID) and for there to be the patient's family involved to support medication adherence. Outpatient follow-up was recommended. The patient was discharged later than same day to her home.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service/treatment of the inpatient stay was not medically necessary for this patient.
The patient presented to the hospital after having had multiple seizures within the course of a day while at home. However, upon arrival to the hospital she was at her baseline. Her neurological exam was non-focal. Her labs showed no significant metabolic abnormalities, nor did she show any hemodynamic instability. She had a non-focal neurological examination. While the patient was taken to the floor, she was only seen by neurology. At that time, it was discovered that the patient had been non-compliant with her prescribed therapy, which was most likely the etiology for her seizures. No neurodiagnostic testing was ordered or otherwise performed for the patient. Her neurological exam was normal, and she was otherwise advised to follow-up as an outpatient and supportive care was recommended.
Given the patient's overall clinical stability in this case, the inpatient level of care would have exceeded the patient's needs for those services which were provided. The patient had no further seizures. She had no clinical worsening while hospitalized (neurologically or otherwise). She had no other significant limitations that would have otherwise necessitated the inpatient setting for the episode of care provided.
Therefore, the inpatient stay was not medically necessary for this patient.