Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension; detox.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

This female patient has a history of hypertension and presented to the emergency department for opioid detox.  She disclosed snorting up to eight bags of heroin per day and being noncompliant with antihypertensives for one month.  

The patient's blood pressure (BP) in emergency department (ED) was 213/118 associated with headache.  Exam was unremarkable.  Labs revealed: white blood cell (WBC) 10.4, hemoglobin/hematocrit (H/H) 14.6/43.6, and platelets (Plt) 214.  Her Clinical Opioid Withdrawal Assessment Score (COWS) was four.  Her basic metabolic panel (BMP) was normal.  Urine toxicology was negative.  Electrocardiogram (EKG) showed normal sinus rhythm with a QTc (corrected QT interval) of 440.  The patient's chest x-ray revealed nothing abnormal detected (NAD).  Chest computed tomography (CT) revealed nothing abnormal detected (NAD).  Head computed tomography (CT) revealed nothing abnormal detected (NAD).  The patient's blood pressure remained elevated at 206/102 despite medications including clonidine, chlorthalidone, and hydralazine.  The patient was admitted on 04/21/2021 with hypertensive urgency.  A nicardipine drip was started.  Repeat blood pressure (BP) was 179/106.  Plan was to start amlodipine.  

The patient's blood pressure was 156/90.  The nicardipine drip was discontinued.  Amlodipine and labetalol were resumed.  The following day, the patient's blood pressure was 151/92.  The patient was cleared for discharge.

No, the proposed treatment was not medically necessary.
Medically necessary services are those which are:
- safe 
- effective
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice.

This patient with a history of hypertension, medical noncompliance and opioid abuse was admitted with hypertensive urgency.  She presented to the emergency department with a blood pressure of 203/118 and for opioid detox.  After receiving several medications in the emergency room, her blood pressure was 206/102.  Her Clinical Opioid Withdrawal Score (COWS) score was four, which is consistent with no signs of withdrawal.  She did not have altered mental status.  Renal function was normal.  Electrocardiogram (EKG) did not show ischemic changes.  Exam did not show findings of end organ damage.  There were no physical signs of withdrawal.  The patient was treated with a nicardipine drip on day #1 and transitioned to home medications on day #2.  Patients without end organ damage have not been shown to benefit from aggressive antihypertensive therapy at an acute inpatient level of care.  Studies show that rapid lowering of blood pressure in these patients offers no benefit, especially if the patient has longstanding severely elevated blood pressure.  These patients can be started on oral antihypertensives with the goal of lowering the blood pressure slowly over 24 to 48 hours.  In addition, she did not have findings of severe withdrawal that required management at an acute inpatient level of care.  Therefore, the inpatient hospital admission was not medically necessary.