Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive urgency

Treatment: Inpatient admission

The insurer has denied coverage for inpatient admission. The denial was upheld.

The patient is a female who presented to the ED with complaints of chest tightness and intermittent left flank pain for 10 days. She experienced substernal tightness that was 5/10 in intensity, non-radiating, with no exacerbating factors; symptoms were relieved with Aspirin. She reported that she had similar episodes two days before that was also relieved with Aspirin. She stated that her blood pressure has been very difficult to control over the past three weeks. She has a past medical history of hypertension and hyperlipidemia. Her initial vital signs in the ED were blood pressure 200/80, pulse 76, respirations 16, temperature 97.9 Fahrenheit and oxygen saturation 100% on room air. On physical exam, there was trace pitting edema of the lower extremities bilaterally. No other abnormalities were noted. The patient received intravenous (IV) Labetalol, Aspirin and sublingual Nitroglycerin, and her repeat blood pressure was 144/63. A CTA showed mild atherosclerotic disease, no pulmonary emboli and a 6 mm right lower lobe nodule with adjacent vascularity. There was no evidence of aortic dissection. The patient was admitted to the telemetry floor because of hypertensive urgency. A nuclear stress test was negative for any reversible ischemia. 

Hypertensive urgency is defined as a severe elevation of blood pressure without target organ damage. In the emergency room, hypertensive urgency has been conventionally managed by antihypertensive medication. However, there has been increasing concern for the safety of antihypertensive medication in hypertensive urgency. Thus, a 2017 study was done to compare the clinical efficacy of resting and antihypertensive medication in managing hypertensive urgency. There was no significant difference between resting and antihypertensive medication in reducing blood pressure of hypertensive urgency patients. This finding suggests the clinical efficacy of resting in managing hypertensive urgency.

This patient presented to the ED with atypical chest pain and systolic hypertension, with an initial blood pressure of 200/80. The response to therapy measured her blood pressure as 144/63. Troponin was negative and certainly would have been expected to be positive, if injury were present, since she had complained of pain for two days. Her EKG showed no evidence of ST segment elevation or T-wave inversion consistent with acute myocardial injury or ischemia. After ACS was ruled out, her physicians thought that she had GERD in addition to hypertensive urgency. The hospital claims that they do not have an observation unit and they claim this is why she was admitted to telemetry. The literature cited makes it clear that admission to any type of unit is not necessary and she could have easily been managed as an outpatient after blood pressure was brought under control. It also suggests that the blood pressure could just as easily be brought under control safely with rest, and shows that telemetry monitoring was not necessary. The record indicates that inpatient admission, specifically to a telemetry unit, was not medically necessary for this patient. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.