Seizures denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided. Findings: The physician reviewer found that the patient is a 53-year-old female who presented to the emergency department with a seizure that had resolved. The patient was visiting her son in the hospital when she began to feel diaphoretic and lightheaded. A nurse witnessed the patient have a convulsion and subsequently lose consciousness for 45 seconds. The patient denied head trauma, chest pain, or sensory or motor changes. Her past medical history included hypertension. Differential diagnoses included seizure, vasovagal, orthostasis, and anemia. Her vital signs were normal. The patient was fully oriented. No cranial nerve deficits were noted and muscle tone was normal.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for genetic testing (whole exome and mitochondrial DNA sequencing). Findings: The physician reviewer found that : the patient with seizures and history of hypoglycemia. The patient has also been diagnosed with hypotonia and developmental delays. She has had an extensive work-up, including metabolic testing, with no definitive answer. There is a likely pathogenic duplication of chromosome Xp11.3p11.23, which overlaps partially with a duplication Xp11.22p11.23 that causes intellectual disability, speech delay, electroencephalogram abnormalities and seizures. The patient’s parent has requested coverage genetic testing (whole exome and mitochondrial DNA sequencing).

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for immediate admission to an acute care hospital.On review of the available documentation, there is a lack of support for the requested immediate admission to an acute care hospital, for either the patient’s hernia or seizures. Typically for hernias, emergent surgery is indicated with incarcerated or strangulated hernias, but otherwise a planned surgery is recommended so the patient can be appropriately prepared for surgery to minimize risk. Although the patient may meet the criteria for surgical hernia repair, the patient should be referred to an in-person visit with the provider to be appropriately evaluated and triaged.

A 24-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his history of seizure caused by withdrawal from drugs. Findings: The physician reviewer found that on the date indicated, the patient reported that he was not experiencing any withdrawal symptoms. The records provided for review do not indicate that the patient’s reported seizure was due to abrupt discontinuation of benzodiazepines. The patient endorsed using Xanax 2 mg three to four times per week mixed with alcohol. His last reported use of alcohol was approximately two weeks prior to admission. By the date indicated, any alcohol would have been out of his system. Further, his last reported use of Xanax was on the date indicated, which was five days prior to his seizure.

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