Seizure Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential mental health and substance for treatment of the enrollee’s behavior health condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The confluence of the patient’s multiple conditions, and their concerning totality of sequelae and subsequent functional impairment with potential for morbidity, warranted aggressive treatment in a supervised setting. Biologically, the patient’s seizure disorder, substance use, and treatment with multiple medications, some of which lower the seizure threshold while others fortify the barrier, introduced a particularly challenging element of complexity and risk for complications.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for substance abuse rehabilitation services at a dual diagnosis facility that provides onsite IV fluids to assist with severe vomiting caused by cyclical vomiting syndrome. The progress notes indicate this patient was admitted with a history of substance use and mood disorder that included depression and anxiety. Applying the American Society of Addiction Medicine (ASAM) criteria for level of placement, the requested services are medically necessary. For dimension 1, the patient presents with acute intoxication and withdrawal potential. She has demonstrated significant withdrawal symptoms including delirium, abnormal lab values, and tachycardia. For dimension 2, the patient has biomedical conditions and complications.

Where the denial was upheld

Findings: The physician reviewer found that The patient has requested reimbursement for residential treatment center (RTC) services (ASAM level 3.5). Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient did not have symptoms of acute withdrawal after detoxification but did report post-acute withdrawal symptoms (PAWS) such as fatigue and aching muscle and joints. The patient’s withdrawal needs were safely managed in a Level 3.5 setting.

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for immunoassay, spectrophotometry and column chromatography/mass spectrometry. The enrollee has a history of viral versus autoimmune meningoencephalitis, seizure disorder and anxiety. The enrollee continues to demonstrate severe anxiety and symptoms of an overstimulated nervous system, despite high doses of anti-epileptic medications. He complains of blurry vision and episodes of vertigo. He underwent a NutrEval, which showed a need for thiamine (vitamin B1) and magnesium. It also showed borderline whole blood mercury, antioxidants within range, and positive dysbiosis markers. The enrollee’s provider recommended benfotiamine daily, magnesium threonate, twice daily and biocidin for treatment of fungal dysbiosis. Labs were re-checked, which showed normal C3/C4 protein levels and elevated serum CH50 levels.

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 seizure disorder, then check the rights and deadlines that apply to your plan.