Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Pressure (during pregnancy). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a G1 (one pregnancy) female. She presented to the hospital from high risk pregnancy clinic due to nonreactive fetal heart rate tracing and borderline elevation of blood pressure to 130/150/90-100.  She complained of mild headache and scotomata. 

The patient's blood pressure on presentation to the hospital was 130-133/82-88. However, serial blood pressures were elevated to 139/93, 132/90, 140/100, 145/96, 156/100, 150/94.  Preeclampsia panel of labs were within normal limits.  Given the rapid escalation of blood pressure and the presence of headache and scotomata, which are symptoms of severe features of preeclampsia with possible CNS (central nervous system) involvement, the patient was admitted for monitoring and administration of antenatal betamethasone. 

Upon admission, the patient experienced irregular uterine contractions and was found to have cervix dilated to 2 cm (centimeters)/30% effaced/-3 station which progressed to 3-4 cm (centimeters). Over the first hospital night the contractions ceased, the cervix did not progress any further, and the elevated blood pressures resolved. The patient was discharged home on hospital day #1.  

The health plan contends that the admission was not medically necessary because although the blood pressures were elevated on admission they returned to the normal range without treatment, there were no signs of premature labor, the maternal and fetal heart rate was not abnormal, liver and kidney function was normal, mental status was normal and there were no headaches or seizures, there was no evidence of fetal growth restriction, and the baby was doing well, and that the care could have been given in the emergency room or observation area. The facility contends that the admission was medically necessary due to elevating blood pressures and rule out preterm labor, and cites 24th edition MCG Hypertensive disorders of pregnancy. 

Yes, the inpatient admission was medically necessary. 

There was a significant concern about preeclampsia with severe features and CNS (central nervous system) involvement given the persistent headache, visual change, and rapidly escalating blood pressures, and the elevated risk given that patient was primigravida.  Severe preeclampsia can lead to catastrophic maternal and fetal complications including abruption, fetal hypoxia and death, maternal renal and hepatic failure, disseminated intravascular coagulopathy, intracranial hemorrhage, pulmonary edema, and death. In addition, the patient had uterine contractions that evoked cervical change to 3-4 cm (centimeters), which meets the case definition of preterm labor due to both advanced cervical dilation in a primigravida patient as well as cervical change to digital exam. Therefore, the patient was at significant risk of a preterm delivery outside of the hospital if she were to have been sent home, with possible consequences of maternal hemorrhage and chorioamnionitis, neonatal hypoxia, respiratory distress syndrome, sepsis, birth injury, and fetal or neonatal death which would be complicated by unattended preterm delivery. Therefore, hospitalization was medically necessary from both fetal and maternal standpoints.