Issued and entered June 11, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On February 28, 2003, XXXXXXXXXXXXXX (Petitioner), filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request for external review.

A determination on medical issues was required. The Commissioner assigned the case to an independent review organization (IRO) to provide the opinion and recommendation of a medical expert. On March 26, 2003, the IRO completed its review and sent its recommendation to the Office of Financial and Insurance Services (OFIS).

II
FACTUAL BACKGROUND

Petitioner is a member of Health Plan of Michigan (HPM). He has a history of seizures including recent episodes (two spells per week) of visual scotomata and disorientation followed by slurred speech, lethargy and chronic headache. The neurologist recommended video/EEG long-term monitoring as an inpatient to diagnose the spells.

Petitioner submitted to HPM a request to authorize 5 days of inpatient testing. The Plan denied the request stating the testing was appropriate only for patients with medically intractable epilepsy. The Petitioner appealed the decision. The Plan sent the case for an independent review which upheld the original denial. The Petitioner received notice of a final adverse determination on February 7, 2003.

III
ISSUE

Did Health Plan of Michigan (Respondent) properly deny authorization and coverage for a 5-Day Inpatient Video EEG Monitoring?

IV
ANALYSIS

Petitioner’s Argument

Petitioner has suffered from seizures for about four years. He saw a neurologist at the XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX. The neurologist stated he had recurrent seizures of uncertain etiology. The doctor also noted his symptoms were more consistent with a migrainous phenomenon. A second type of seizure may be psychogenic in nature. The doctor planned to admit the Petitioner for video/EEG long-term monitoring for a more definitive diagnosis.

On XXXXXXXXXXXXX, Petitioner consulted with Dr. XXXXXXX, M.D. The physician wrote a letter, dated XXXXXXXXXXXXXXXX, referencing a previous neurologist who referred Petitioner to the University of Michigan clinic. The doctor also reported another episode described as being able to talk but being disoriented until the next morning. The doctor wrote:

This letter is being written in regards with the patient verifying the need and acute nature of his illness and the appropriateness of the workup requested. It is felt to be [in] the best interest of the patient to have this fully worked up and treated.

The Petitioner continued to report refractory headaches and seizures at a XXXXXXXX XXXX visit. The doctor adjusted the medications and the patient was to return in three months. In lieu of the long term monitoring approval, the plan was to proceed with a short-term 6-hour monitoring and refer patient to the Pain Clinic for evaluation and management of his chronic headaches.

Health Plan of Michigan’s Argument

The Certificate of Coverage in Section II-Q allows HPM to require prior approval for utilization management purposes as long as the procedures do not avoid providing medically necessary services. Additionally, Section II-H allows HPM to limit services to those which are medically necessary and appropriate, and which conform to professionally accepted standards of care.

Petitioner requested the 5-Day Inpatient Video EEG Monitoring to definitively diagnose the “spells.” The Plan determined the test to be inappropriate for the patient’s circumstances, explaining:

This test is indicated only for possible surgical intervention of an individual with known history of seizures proven refractory to good faith attempts with medication, not to confirm a diagnosis. Therefore, the request is denied at this time. Our Physician Reviewer suggests that you discuss other, alternative forms of treatment with your physician.

On appeal, the Plan sent the case to an independent review organization. The reviewer concluded there was no documentation that the patient has medically intractable epilepsy that failed usual and customary intervention. There was insufficient evidence to indicate medical necessity for inpatient video EEG monitoring. The episodes are not life-threatening and have not been evaluated adequately under the possibilities of migraine and/or anxiety.

IRO Recommendation

The independent medical expert is board certified in Psychiatry by the American Board of Psychiatry and Neurology. The expert agrees with the denial of a 5-Day Inpatient Monitoring for the Petitioner and states:

[A] repeat EEG or even a 24 to 48 hour ambulatory monitor would be more appropriate given the frequency of the seizures. It is very possible that one of these episodes may be picked up on in either of these two studies and the diagnosis confirmed. This reviewer thinks that these are necessary as the preliminary step prior to resorting to a more expensive and possibly less fruitful …monitoring.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents presented by the parties in this case, as well as the findings of the IRO. The focus of this analysis is whether Health Plan of Michigan properly denied Petitioner authorization for 5-Day Inpatient Video EEG monitoring in order to diagnosis his seizure disorder.

The Commissioner agrees with the IRO’s conclusion that the inpatient monitoring for the Petitioner’s seizure disorder of unknown etiology is not medically necessary. The Petitioner’s seizures are not described as life threatening. Medical reviewers recommended other studies and interventions for diagnosis and treatment that appear reasonable. The IRO suggests other preliminary steps may be more appropriate to confirm a diagnosis rather than resorting to inpatient testing.

V
ORDER

The Commissioner upholds Health Plan of Michigan’s adverse determination of February 7, 2003. Respondent is not required to authorize a 5-Day Inpatient Video EEG monitoring procedure for the Petitioner.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.