Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive urgency
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The determination is upheld.

The patient is a male who presented to the emergency department (ED) with severe uncontrolled hypertension (HTN). The patient was complaining of a mild headache according to the ED) records. The patient did not have changes in vision, denied chest pain and shortness of breath (SOB). The medical team noted blurry vision for 2 to 3 weeks. The patient did not receive his medications from the pharmacy and he was not taking his medications.

The patient was admitted to the hospital 4 days prior to this admission. The patient recently underwent an echocardiogram which showed his left ventricular ejection fraction (LVEF) was 55-60 percent (%). The echocardiagram also showed a grade II diastolic dysfunction, severe left ventricular hypertrophy (LVH) and a normal left atrial size. A computed tomography (CT) that was completed was unremarkable.

The patient has end stage renal disease, is on hemodialysis and has sickle cell trait. His blood pressure (BP) in the ED was 200/141 in triage. A repeat BP was 213/146, heart rate was 98 and his temperature was normal. The patient's oxygen saturation was 97 percent (%) on room air and the patient was alert and oriented times 3. He is obese with bilateral extremity edema. The patient's chest was clear. His high sensitive troponin level was 174.6, white blood cell count (WBC) was 11.1, hemoglobin (Hgb) was 7.9 and platelets were 265. His creatinine was 7.79 and blood urea nitrogen (BUN) was 57.5. The brain (or B-type) natriuretic peptide (BNP) was 666. The patient's electrocardiogram (ECG) revealed sinus rhythm with left atrial abnormality and LVH with repolarization abnormality. The chest x-ray revealed an enlarged cardiac silhouette. The patient was treated with oral Hydralazine and Nifedipine.

A cardiology consultation was done and the patient was treated with Procardia, Labetalol and Hydralazine. A nephrology consultation was done and hemodialysis was ordered and the patient underwent hemodialysis. The patient was treated with oral medications. His BP went down and his condition was stable.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of inpatient hospital admission was not medically necessary.

The patient presented with very high BP, mostly due to noncompliance with medications. However, there was no evidence of acute end organ damage due to hypertension. Therefore, the patient did not have a hypertensive emergency. There was no evidence of hypertensive encephalopathy, the patient was alert and oriented and had a mild headache and possibly blurred vision for 3 weeks, which means there was no acute brain damage due to an elevated BP. The patient did not have new neurologic deficit. The patient was not in congestive heart failure (CHF) and did not have angina. He had leg edema, possibly chronic. His chest x-ray did not reveal CHF, he did not have crackles on physical examination and did not complain on dyspnea. His BNP was elevated, but not necessarily acute and this could be his baseline. His troponin was elevated, but the patient was on dialysis, and it could have been a chronic troponin elevation. He did not have chest pain and his ECG did not reveal any acute ischemic changes.
Therefore, based on above, the patient did not have acute neurologic or cardiac damage due to his elevated BP. His kidneys were chronically not functional.