Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension during pregnancy. 
Treatment: Inpatient admission. 

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

This is a female patient with 35 weeks of gestation who presented to the Emergency Department (ED), referred by her Obstetrician for complaints of hypertension during pregnancy with blood pressure of 148/86. The patient was admitted to the maternity unit for further evaluation. The patient's fetal non-stress test was reactive with baseline of 140, moderate variability and no contraction. The hospital course of treatment and management included fetal heart rate monitoring and tocodynamometer monitoring. After treatment, the patient was discharged home. 

Based on the review of the medical record, the patient's documented blood pressures on admission were 120-155/60-70 but were not significantly elevated compared to her baseline/discharge blood pressures, which were noted to be 125-140/75-90. During the hospital stay, the patient's blood pressures were within normal range. The patient presented to the hospital with minimally elevated blood pressure that improved without any treatment. The patient had no vaginal bleeding, no uterine contractions and no ruptured membranes. There was no evidence of fetal compromise. The patient's laboratory evaluations were normal. The patient's non-stress tests were reactive, and the biophysical profile was normal. 

As per literature review, 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 Obstetricians and Gynecologists (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. In this case, this patient did not even have hypertension. The patient's blood pressures during her hospital stay were normal. 

The patient does not fulfill the InterQual criteria Hypertensive Disorders of Pregnancy for hospital admission. Specifically, the patient did not have: hemolysis, elevated liver enzymes, low platelet (HELLP) syndrome; systolic blood pressure above 160 and diastolic above 110; platelets less than 100,000; severe preeclampsia or eclampsia; onset of seizures; fetal compromise; hemodynamic instability; hypertension and acute end-organ damage. This patient did not have any of these symptoms or signs. The patient could have been safely observed for a few hours, labs could have been obtained and when the provider ascertained that the blood pressure was normal and there was no evidence of severe preeclampsia, the patient could have been sent home to be followed closely as an outpatient. Nothing was done in the hospital that could not have been done as an outpatient. Since the patient did not have preeclampsia but some mild elevation of her blood pressure that normalized, admission was not medically necessary for this patient.

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

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