Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pregnancy/Childbirth/Hypertensive Disorder of Pregnancy, Preeclampsia in Postpartum Period.
Treatment:  Inpatient Hospital Admission.

The health plan denied the inpatient hospital admission as not medically necessary.  The health plan's determination is overturned.

This is the case of a female, who presented to the emergency department (ED) complaining of a headache. The patient is five days out from a primary C-section and returned to the hospital with complaints of an elevated blood pressure, headache, and blurred vision. Obstetrics/Gynecology (OB/GYN) was asked to evaluate the patient, and documented a blood pressure of 135/80 millimeters of mercury (mmHg), a pulse rate of 70 beats per minute (bpm), and respirations of 19/minute. Labs showed a hemoglobin of 8.7, a normal white blood cell count, and normal platelets. Renal function was unremarkable. The lactate dehydrogenase (LDH) was slightly elevated to 255, with normal liver function tests (LFTs). The OB/GYN team was worried about preeclampsia and started the patient on Nifedipine 30 milligrams (mg). The patient was also given Benadryl and Reglan, which improved the headache. Preeclampsia labs were within normal limits.

The patient was started on a magnesium infusion for seizure prophylaxis. The patient had tried Motrin and Tylenol at home for the headache, which did not relieve the symptoms. She also complained of sharp epigastric pain but no right upper quadrant pain. She was not on any chronic blood pressure medications at home.

Subsequent blood pressures were still somewhat elevated at 159/97 mmHg with a normal heart rate. On exam, the patient had a regular rate and rhythm, clear lungs, and a soft abdomen. She had lower extremity edema, negative calf tenderness, and normal reflexes. There were no signs of magnesium toxicity with the intravenous (IV) magnesium infusion. The patient was experiencing excellent diuresis.

Later in the day, the patient's blood pressure improved to 130 mmHg. By the evening hours, the patient was awake and alert and denied headache, chest pain, or shortness of breath. Epigastric pain resolved. Fluid status showed a net negative of 4.4 liters of urine. The IV magnesium was continued for a total of 24 hours. The hemoglobin improved to 9.2 grams/deciliter (g/dL), the electrolytes and renal function remained stable, and so were the LFTs. The OB/GYN documents that the patient's preeclampsia has resolved. The plan is to discharge the patient home with Procardia and have a 72-hour blood pressure check.

At issue is the medical necessity for the inpatient stay.

I overturn, in whole, the health plan's determination of medical necessity.

Yes. Inpatient hospitalization was warranted in this case. Based on the provided documentation, inpatient hospitalization was indicated for this patient. Based on the provided documentation, the patient was experiencing preeclampsia, with vision changes, epigastric pain, and elevated blood pressure, which qualify for inpatient admission. This condition is typically treated in the inpatient setting, with continuous infusion of magnesium and antihypertensive medications. Infusion of magnesium requires frequent checks for magnesium toxicity, monitoring of the strict ins and outs, and serial monitoring of LFTs and chemistry panel. The acuity and complexity of care could not have been delivered in an observation setting. The clinical guidelines are clear that an inpatient admission was indicated.