Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gestational hypertension
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient is pregnant with complaint of elevated blood pressure at home (150/90 and 140/90). She also reported headache. The patient has type 2 diabetes on insulin pump. Laboratory evaluation was negative. The patient had an elevated Hemoglobin A1C. She was evaluated by medical endocrinology. She was discharged after two hospital days.

According to the medical records, the patient was admitted for the following reasons:
Elevated blood pressure at home to rule out preeclampsia and diabetic control.

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 or higher, or diastolic blood pressure of 110 or higher) should be diagnosed with preeclampsia with severe features. These severe ranges of blood pressure increase the risk of morbidity and mortality.

According to the American College of Obstetrics and Gynecology (ACOG), ambulatory management at home is an option only for women with gestational hypertension or preeclampsia without severe features and requires frequent fetal and maternal evaluation. Hospitalization is appropriate for women with severe features. This patient did not have preeclampsia. She had a mild elevation in blood pressure that stabilized without any medication. In addition, there was no protein in the urine and her laboratory evaluation was normal.

People with diabetes are usually admitted if they have the following: Life-threatening acute metabolic complications of diabetes or severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes. This patient had none of the these. Based on the above, admission for glucose control was not medically necessary. The patient could have been followed up closely (daily in the clinic) for dose adjustment.

Please note that neither the patient nor the fetus were in any jeopardy. Fetal heart rate was reassuring. There was no evidence of ruptured membranes.

Milliman Care Guidelines list the following clinical indication for admission:
Condition requiring premature delivery; Delivery; Fetal distress or demise; Significant maternal disease, infection or comorbidity as cause; Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete; Continued fetal monitoring; Tocolytic therapy that requires inpatient care; Complications of tocolytic treatment.
This patient did not have any of the above.

Based on the above, the acute inpatient admission was not medically necessary for this patient. The patient could have been managed at the observation level of care.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.