Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy-induced hypertension; diabetes

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.
The denial is upheld.

The patient is a female G4P2 who presented with complaint of elevated blood pressure. The patient's history was significant for poorly controlled diabetes. The patient's blood pressure was 138/85. The patient's laboratory evaluation was normal. The patient was admitted for blood sugar, blood pressure monitoring, and 24-hour urine collection. The progress note documented that the patient's blood pressure ranged from 130/70 to 130/80. The patient was seen by maternal-fetal medicine (MFM) specialist and as per MFM, the patient did not have a diagnosis of preeclampsia; the patient's diagnosis was pregnancy-induced hypertension (PIH). The patient had poor compliance with her sugar control. The patient was counselled and discharged home to be followed as an outpatient.

Based on the review of the medical record, the patient was admitted for 2 clinical conditions, which were poorly controlled diabetes and elevated blood pressure in the setting of pregnancy.

As per literature review, inpatient admission is medically necessary for patients with diabetes if they have life-threatening acute metabolic complications of diabetes; substantial and chronic poor metabolic control that necessitates close monitoring of the patient to determine the etiology of the control problem, with subsequent modification of therapy; and/or severe chronic complications of diabetes that require intensive treatment or sever conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes. In this case, the patient did not have any of these conditions. The patient's etiology of the control problem was noncompliance to her medication treatment. 

As in terms of this patient's elevated blood pressure, the patient had an episode of mildly elevated blood pressure. As per MFM consult, the patient did not have preeclampsia but had pregnancy-induced hypertension. 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. According to MCG guidelines for admission, clinical indications for admission include one/more of the following: severe preeclampsia or eclampsia; onset of seizures; fetal compromise; hemodynamic instability; hypertension and acute end organ damage. In this case, the patient did not have this clinical indication. The patient had mild blood pressure elevation, and her laboratory evaluation was normal. There was no clinical evidence of pre-eclampsia. The patient could have been followed closely with frequent blood pressure and fetal monitoring as outpatient. Inpatient admission was not medically necessary.

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated