Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gestational hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a pregnant female at 34.3 weeks of gestation who presented to the hospital as a transfer from another facility with suspected preeclampsia because of a low platelet count. She had a 24-hour urine collection a week before presentation that was normal. The thrombocytopenia predated the mild elevation of blood pressure. 24hour urine protein was negative. She was admitted with a diagnosis of gestational hypertension rather than preeclampsia for monitoring.

Her blood pressure was within normal limits to mildly elevated. Laboratory evaluation was normal except for decreased platelets count. Urine protein was negative. Fetal heart rate was reassuring, and the patient was discharged home.

According to the medical records, the patient was admitted for the following reasons:
Gestational hypertension for monitoring.

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 or higher, or diastolic blood pressure of 110 or higher) should be diagnosed with preeclampsia with severe features. These severe ranges of blood pressure increase the risk of morbidity and mortality.

According to American College of Obstetricians and Gynecologists (ACOG), hospitalization is appropriate for women with severe features. This patient did not have preeclampsia. She had a mild elevation in blood pressure that stabilized without any medication. In addition, there was no protein in the urine and her laboratory evaluation was normal except for low platelet count that predated any increase in blood pressure.

This patient could have been observed. Once her laboratory evaluation returned normal and no significant elevation of her blood pressure was noted, she could have sent home without the need for admission. Neither the patient nor the fetus was in any jeopardy. Fetal heart rate was reassuring. There was no evidence of ruptured membranes.

Milliman Care Guideline (MCG) Inpatient and Surgical care. Criteria for antepartum admission lists clinical indication for admission to include:
Condition requiring premature delivery; Delivery; Fetal distress or demise; Preterm labor and positive fetal fibronectin (fFN); Significant maternal disease, infection, or comorbidity as cause; Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete; Continued fetal monitoring; Tocolytic therapy that requires inpatient care; Complications of tocolytic treatment

This patient did not have any of the above. Based on the above, the acute inpatient hospital admission was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.