Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive emergency.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for uncontrolled hypertension, seizure disorder, chronic obstructive pulmonary disease (COPD), asthma, and hyperlipidemia who presented to the emergency department with complaints of abdominal pain.
The abdominal pain was located in the epigastrium and periumbilical area. The patient described the pain as cramping, 5/10 in intensity, intermittent, non-radiating. There were no aggravating or alleviating factors. The pain started one day before the day of admission. In addition, the patient complained of non-exertional chest pain and intermittent shortness of breath as well as nausea. These symptoms had been going on for 1 to 2 days.
The patient denied any vomiting, diarrhea, lower abdominal pain, urinary complaints, headache, neck pain, fever, chills, recent illness, or sick contacts. On physical exam, the patient's temperature was 99.3 degrees Fahrenheit, blood pressure 196/102, respiratory rate 15, and oxygen saturation 99%.
The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation without wheezing, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdominal exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 9.0, hemoglobin 12.9, hematocrit 38.4, and platelets 324. Sodium was 139, potassium 4.3, chloride 102, bicarbonate 26, blood urea nitrogen (BUN) 19.9, and creatinine 1.84. A urinalysis was unremarkable. Creatine phosphokinase (CPK), troponin was minimally elevated.
At the time of the initial evaluation, the patient was diagnosed with a hypertensive emergency, which according to the admitting physician resolved. Other clinical diagnoses included chest pain, gastroesophageal reflux disease (GERD), acute kidney injury, seizure disorder, chronic obstructive pulmonary disease (COPD).
In the hospital, the patient was seen by a cardiologist who recommended ruling out acute coronary syndrome and continuing treatment with Aspirin and Lipitor. The cardiologist also diagnosed the patient with a hypertensive emergency/urgency but stated that the last blood pressure was 159/89. The cardiologist recommended the continuation of treatment with Procardia.
During the hospital stay, the patient remained afebrile and hemodynamically stable. His hypertension and kidney function improved, and the patient was discharged home on the next day after the day of admission. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
In this clinical case, the patient presented to the hospital with complaints of abdominal pain, intermittent chest pain. The patient was found to have severely elevated blood pressure and was diagnosed with a hypertensive emergency. He was admitted to the hospital because of the hypertensive emergency, acute kidney injury, and chest pain to rule out acute coronary syndrome.
Per the Merck Manual Professional Version online, specifically the Hypertensive Emergencies chapter:
"A hypertensive emergency is severe hypertension with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys). Diagnosis is by blood pressure (BP) measurement, electrocardiogram (ECG), urinalysis, and serum blood urea nitrogen (BUN) and creatinine measurements." Based on the clinical history and results of the physical exam, it was clear that the patient had no brain damage as a result of the severely elevated blood pressure.
There was no evidence of acute coronary syndrome or congestive heart failure. The cardiologist indicated that the patient's slightly elevated troponin level was at the patient's baseline.
Regarding whether the patient had any significant kidney damage as a result of the severely elevated blood pressure, the KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for Acute Kidney Injury definitions were utilized. Based on the guidelines, acute kidney injury is diagnosed with an increase in the serum creatinine value of greater than or equal to (>=) 0.3 milligrams per deciliter (mg/dL) (26.52 micromol/L) in 48 hours, or increase in serum creatinine of >= 1.5 times baseline within the prior 7 days, or urine volume less than (<) 0.5 milliliters per kilogam (mL/kg) /hour for 6 hours. The review of the medical records did not demonstrate that the patient met those criteria, because it was unknown what was the timeframe when the patient's creatinine rose above the baseline.
In addition, there was no evidence that the patient had abnormalities in the urinalysis typical for renal involvement, which included a significant amount of red blood cells, red blood cell (RBC) casts, or significant proteinuria. The patient's creatinine went down from 1.84 to 1.42 within the first day of the hospitalization.
The blood pressure was brought down very quickly and remained within a reasonable range. Overall, the patient's hospitalization was very short and the patient was discharged home on the next day after the day of admission.
Taking into consideration all of this information, the patient had hypertensive urgency, the condition that is associated with severely elevated blood pressure without target-organ damage. In general, the treatment of hypertensive urgency does not require admission to the hospital. In this clinical situation, upon initial evaluation, it was unclear if the patient had hypertensive urgency or hypertensive emergency. In addition, acute coronary syndrome needed to be ruled out.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care . The patient's elevated blood pressure came down very quickly. There was not clear evidence that the patient had true target-organ damage required for the diagnosis of hypertensive emergency. The mild increase in the creatinine level improved very quickly within the first day of hospitalization. The patient's blood pressure also improved within a short period of time. Care could have been provided at a lower level.