Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a male with a past medical history significant for uncontrolled hypertension, benign prostatic hyperplasia (BPH), left calf ulcer, alcoholism, and schizophrenia who presented to the emergency department requesting detox from alcohol. The patient was observed in the emergency department and was given medications for uncontrolled hypertension. Upon arrival in the psychiatric emergency department, the patient's blood pressure was 176/102. Subsequently, multiple readings were around 200/100 millimeters of mercury (mmHg). 

The admitting physician stated that the medical team was consulted for admission, considering the fact that the patient's blood pressure remained significantly elevated despite treatment. The review of systems obtained was positive for urinary frequency and urgency, and the occasional sense of incomplete bladder emptying. These symptoms improved. The patient complained of pain in the left leg/ankle related to the open wound.  The review of systems was negative. 

The vital signs were a temperature at 97.5, pulse rate was 75 beats per minute (bpm), respiratory rate was 18, blood pressure was 176/102, and oxygen saturation was 96% on room air. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. His lungs were clear to auscultation. The patient had a regular rate and rhythm. 
The patient was admitted to the hospital with a diagnosis of hypertensive urgency, history of hypertension, ankle ulcer, BPH, hallucinogens (phencyclidine) (PCP) abuse, and alcohol use disorder. The patient was treated with several medications to lower the blood pressure. The admitting physician stated that there were no alcohol withdrawal symptoms. 

The patient was evaluated by a psychiatrist who determined that he had the capacity to make his own decisions. Therefore, the patient was allowed to sign out against medical advice on the next day after the day of admission. 

At issue is the medical necessity of the inpatient stay. 
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient stay was not medically necessary for this patient. 

The review of the medical records demonstrated that the patient had hypertensive urgency, a condition that does not require admission at the acute inpatient level of care. 
Based on the accepted standards of care, admission at the acute inpatient level of care is recommended for cases of hypertensive emergency which is defined as systolic blood pressure greater than 180 mmHg or diastolic blood pressure greater than 120 mmHg with evidence of acute or worsening target organ damage such as hypertensive encephalopathy (altered mental status), cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine with reduction of more than 50% in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, or seizure. 

Even though the patient presented to the hospital to get detoxification from alcohol, there was no evidence that he had alcohol withdrawal symptoms. On the next day after the day of admission, the patient was seen by a psychiatrist who determined that the patient was able to make his own decisions and did not require involuntary hospitalization. Overall, he remained in stable condition and did not require any diagnostic studies or procedures necessitating admission at the inpatient level of care.
Therefore, the requested health service/treatment of inpatient stay was not medically necessary for this patient.