Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Pressure (post partum hypertension).
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is overturned. 

The patient is a P1 (one birth) female. She was admitted postpartum postoperative day 5 status post Cesarean section.  The pregnancy was complicated by intrapartum gestational hypertension.  At the time, she presented postpartum, she complained of elevated blood pressures and a headache.  Blood pressures were reported to be in the 120s-150s/80s-100s with one severe range pressure of 168/90. 

The patient's blood pressure was measured on the arrival to the ED (emergency department) to be 160/92.  There were no clinical or laboratory signs of severe features of preeclampsia other than persistent headache, which did not resolve until the day after admission.   Her labetalol was increased to 200 mg (milligrams) BID (twice daily).  An MRI (magnetic resonance image) was ordered for the persistent headache, but was not performed because the headache resolved and she was discharged on hospital day #1.  

The health plan contends that the admission was not medically necessary based on MCG (Milliman Care Guidelines) 24th edition Hypertensive Disorders of Pregnancy and that observation may have been an option per MCG 24th Edition Hypertensive Disorders of Pregnancy Observation Care.  The facility contends that acute medical management was evidenced by presenting factors, significant abnormal findings, risk factors, and medically necessary treatment and states that the admission is supported by MCG guidelines 24th edition.

Yes, the Inpatient admission was medically necessary.  

It has become increasingly clear that a higher level of suspicion needs to be utilized for patients presenting with symptoms of headache in the context of pregnancy-induced hypertension to prevent complications, including maternal mortality.  Quoting from the most recent relevant practice bulletin from the American College of Obstetricians of Gynecologists, "It is important to increase the awareness among health care providers and to empower patients to seek medical advice if symptoms that precede eclampsia, hypertensive encephalopathy, pulmonary edema, or stroke are noted in the postpartum period.  Most women who present with eclampsia and stroke in the postpartum period have these symptoms for hours or days before presentation." 

This patient had documented blood pressure elevation into the severe range in the Emergency Department, a persistent headache despite analgesics, and a history of gestational and intrapartum hypertension as well as elevated blood pressures in the postpartum period.  Although she did not exhibit laboratory evidence of severe features of preeclampsia, it is essential to consider the persistent headache in this context as possible evidence of CNS (central nervous system) involvement of either preeclampsia or other pathology such as cerebral venous thrombosis that require emergent treatment.  

The consequences of untreated preeclampsia include pulmonary edema, ARDS (acute respiratory distress syndrome), liver and renal failure, liver capsule rupture, intracranial bleeding, stroke, eclamptic seizures, and death.  Therefore, it was medically necessary to observe this patient for possible progression of her hypertensive disease as an inpatient, and therefore the admission was medically necessary.