Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and hypertensive urgency
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This male was hospitalized for chest pain and hypertensive urgency. His past medical history was remarkable for hypertension, diabetes, chronic kidney disease, hyperlipidemia and cardiac catheterization about a year ago showing nonobstructive coronary artery disease (CAD) to be treated medically. The initial blood pressure reading in the emergency department (ED) was 159/101 followed by 180/40. Heart rate was between 61 and 79. Electrocardiogram (EKG) showed sinus rhythm and abnormal QRS -T angle, consider primary T-wave abnormality. The patient's troponin panel was negative times two (x2) specimens. His potassium was 5.6, blood urea nitrogen (BUN) was 42, and creatinine was 1.67. 

The patient was seen by Cardiology and the clinical impression was chest pain of musculoskeletal origin from heavy lifting. The patient's antihypertensive medications were adjusted and he was deemed medically stable and discharged home.  The request for coverage for inpatient hospital admission was denied and the patient is appealing the decision.

No, the proposed inpatient hospital admission was not medically necessary.

The requested acute inpatient hospital stay was not medically necessary in this particular case, per the provided 22nd Edition Milliman Care Guidelines: Hypertension ORG: M-197 (ISC).  The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. 

There was no documentation submitted to meet inpatient level of care, including:
1) hypertensive emergency with evidence of acute and progressing target organ disease, such as, hypertensive encephalopathy/altered mental status or cerebral infarction or intracranial hemorrhage or myocardial ischemia or infarction or heart failure with pulmonary edema, or 
2) aortic dissection, or
3) increased creatinine (new) with reduction of more than 50% in estimated glomerular filtration rate from baseline, or
4) papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, or 
5)seizure, or
6) adrenergic or sympathomimetic crisis, such as severe hypertension due to pheochromocytoma crisis; cocaine, phencyclidine, or amphetamine intoxication or clonidine withdrawal, or
7) severe hypertension (systolic blood pressure [SBP] greater than 180 millimeters of mercury [mmHg] or diastolic blood pressure (DBP) greater than 110 millimeters of mercury (mmHg) that cannot be controlled (eg, to systolic blood pressure [SBP] less than 160 millimeters mercury [mmHg] and diastolic blood pressure [DBP] less than 100 millimeters mercury [mmHg] in adults) by emergency department or observation care treatment. 

The care the patient received for chest pain presumed to be from musculoskeletal origin and hypertensive urgency and not hypertensive emergency is routinely provided at a lower level of care and is considered the standard of care for this patient. Therefore, inpatient admission was not medically necessary, based on the submitted information and the current published medical guidelines.

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