Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld in whole. 

The patient is a female who initially presented to the emergency department for recurrent epistaxis associated with headache and dizziness. Her pertinent history included recurrent epistaxis, hypertension, and diabetes mellitus type 2. Her initial vital signs revealed a temperature of 97.5, heart rate (HR) was 91, blood pressure (BP) was 197/110, respiratory rate (RR) was 16, and peripheral capillary oxygen saturation (SpO2) was 97% on room air. The initial examination documented the patient with a normal nose without bleeding. 

Serology revealed a white blood cell count (WBC) at 9.1, hemoglobin (Hgb) was 14.9, platelets (Plt) were 240, blood urea nitrogen (BUN) was 15, creatinine (Cr) was 0.9, glucose (Glu) was 168, and Troponin I was 0.10 (0.045 normal). Amlodipine and hydralazine were administered. 

The patient was placed in the hospital with an impression of epistaxis, elevated troponin, and hypertensive urgency. Treatment plan included an echocardiogram, serial troponin levels, resumption of home oral anti-hypertensives, and cardiology consultation. Cardiology consultation was obtained who had an impression of borderline, flat-trending troponin likely due to hypertensive crisis. The recommendations were oral anti-hypertensive adjustments, discontinuation of telemetry, and an outpatient echocardiogram. 

The patient was deemed medically stable and discharged. 
At issue is the medical necessity of the inpatient stay. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient stay was not medically necessary for this patient. 

The acute inpatient level of care was not indicated as medically necessary for the entire admission. 

The patient had a history of hypertension and epistaxis who presented with severe hypertension. There was no active epistaxis, and none occurred during the hospitalization. Serology was unremarkable with notable borderline, flat troponin levels. Cardiology consultation was obtained who did not feel an acute myocardial infarction was present and recommended discontinuation of telemetry with an outpatient echocardiogram. With oral anti-hypertensives, blood pressure control was achieved. 
Rodriguez et al. discussed the evaluation and management of a Hypertensive crisis. They note that an uncontrolled hypertension can progress to a hypertensive crisis defined as a systolic blood pressure >180 millimeters of mercury (mmHg) or a diastolic blood pressure >120 mmHg. Hypertensive crisis can be further classified as a hypertensive urgency or hypertensive emergency depending on end-organ involvement including cardiac, renal, and neurologic injury. The prompt recognition of a hypertensive emergency with the appropriate diagnostic tests and triage will lead to the adequate reduction of blood pressure, ameliorating the incidence of fatal outcomes. Severely hypertensive patients with acute end-organ damage (hypertensive emergencies) warrant admission to an intensive care unit for immediate reduction of blood pressure with a short-acting titratable intravenous antihypertensive medication. Hypertensive urgencies (severe hypertension with no or minimal end-organ damage) may in general be treated with oral anti-hypertensives as an outpatient.[1] In this particular situation, the patient met criteria for a Hypertensive crisis. She then met the subset criteria for the diagnosis of Hypertensive urgency, which in general is not treated at the inpatient level of care. 

Therefore, the inpatient stay was not medically necessary for this patient.