Epilepsy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for long-term continuous video electroencephalogram monitoring (CPT 95700) during an inpatient hospital stay (5-day hospital stay).Whittaker states that epilepsy is a clinical diagnosis based on the history of the patient and of witnesses. Whitaker states that sometimes this is not available or is incomplete, thus making diagnosis uncertain. In other cases, specifically in patients with intractable epilepsy being considered for epilepsy surgery, the diagnosis of epilepsy is not in doubt but the precise localization of the epileptogenic zone needs to be determined. Whitaker explains that in both of these situations, video telemetry plays a key role and is now a routine in most neuroscience units.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for any or all of the requested neuropsychological testing services (psychiatric diagnostic evaluation; one hour – psychological and neuropsychological testing; and two additional hours – psychological and neuropsychological testing) in addition to the approved neuropsychological and psychological testing (one hour and three hours) are medically necessary for the evaluation of this patient. In a summary of the required testing for surgical pre-operative planning for epilepsy, researchers suggest that in the surgical setting, in addition to formal neuropsychological test scores, behavioral measures of cognitive function are useful, together with subjective ratings of the patient’s difficulties in each cognitive domain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gralise. A researcher explains, “The management of patients with epilepsy is focused on three main goals: controlling seizures, avoiding treatment side effects, and maintaining or restoring quality of life. Clinicians should assist in empowering patients with epilepsy to lead lifestyles consistent with their capabilities. The optimal treatment plan is derived following an accurate diagnosis of the patient's seizure type(s), an objective measure of the intensity and frequency of the seizures, awareness of medication side effects, and an evaluation of disease-related psychosocial problems.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for air ambulance service provided on 12/27/17. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees epilepsy.At issue in this case is whether the requested air ambulance service was medically necessary for treatment of the enrollees medical condition.In most cases, air ambulance transport is reserved for use in emergent situations in which ground transport is not feasible or readily available. Such situations from the neurology perspective include (but are not limited to), intracranial hemorrhages, strokes requiring endovascular therapy or other conditions requiring acute surgical intervention.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving epilepsy, then check the rights and deadlines that apply to your plan.