Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Hypertension during Pregnancy
Treatment: Inpatient Hospital Admission
The insurer denied the hospital stay.
The health plan's determination is overturned.

This patient is a who presented with new hypertension. The patient is at 23-1/7 weeks gestational age by her last menstrual period (LMP) which is consistent with a 14-week ultrasound with presentation from the maternal fetal medicine (MFM) office for elevated blood pressures. She was known to have an abnormal non-invasive prenatal test (NIPT) testing with low fetal fraction and was counted to have a blood pressure of 160-180/120's in the office. She had a history of chronic hypertension that was not managed on medications. She had no complaints of headache, changes in vision, shortness of breath, chest pain, right upper quadrant pain or epigastric pain. She denied contractions, leaking of fluid or vaginal bleeding. 

For her prior medical history of chronic hypertension, she was previously on Lisinopril and HCTZ and they were stopped with this pregnancy. The patient received Labetalol 20, 40 and 80 milligrams (mg) intravenous (IV) push and was started on oral antihypertensives after admission. She continued on a Prenatal Vitamin and Aspirin 81 mg. Fetal testing was reassuring and Category I. The patient had a blood pressure (BP) on admission of 158/100 and then 160/100 followed by 147/101. The patient was to have Magnesium if her BP remained in the severe range. An ultrasound was noted for a normally grown fetus at the 47 percentile without any anomalies. The hemolysis, elevated liver enzyme levels and low platelet count (HELLP) laboratory studies were normal. Her platelets were normal. There was no laboratory evidence of hemolysis. The patient's creatine clearance, serum creatinine and liver functions were normal. A 24-hour urine was completed and was 182 mg/24 hours.

The patient was then given oral immediate release Procardia for blood pressure control. Magnesium sulfate was given for severe range blood pressures. The patient was given Labetalol 20 mg IV push given severe range BP and headache. The patient was ordered for a course of Betamethasone for fetal lung maturity. She was also given Procardia 60 extended release (XL) for blood pressure control.
The patient denied headache, vision changes, chest pain, shortness of breath, epigastric/right upper quadrant (RUQ) pain, and nausea and vomiting. She remained stable with a normal examination. Her blood pressure was better controlled at 146/94. She was on Procardia XL 60 each (q) day. Magnesium was continued for completion of steroids. Dose 2 of Betamethasone was administered to the patient. Magnesium Sulfate was planned for 24 hours. Fetal monitoring was reassuring. She was to have a baseline electrocardiogram (EKG) completed.

Based upon her review of the medical records in this case and the 26th Edition Milliman Care Guidelines (MCG) Care Guidelines entitled "Hypertensive Disorders of Pregnancy", there would be medical necessity for acute inpatient care based upon these guidelines reviewed along with the medical records.
In consideration for admission to the acute inpatient care, the MCG guideline would recommend admission as medically necessary for eclampsia, planned delivery, severe preeclampsia with new onset seizures and hypertension with acute end organ damage as indicated by one or more of the following: hypertensive encephalopathy, cerebral infarction, intracerebral hemorrhage, visual loss, unstable angina, myocardial infarction, acute pulmonary edema, aortic dissection, seizures, or acute renal failure. In this case, all of these findings were absent and lab testing was normal. However, the guidelines also recommend admission to acute inpatient level of care for systolic blood pressure in excess of 160 and diastolic in excess of 110.