Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypertension.
Treatment:  Inpatient admission.

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

This case involves an adult patient, who presented to the emergency department complaining of numbness to the left face and left arm for 2 hours. The patient had a history of hypertension, mitral valve prolapse, and prior vascular accident (CVA). The patient claimed that symptoms had since abated but described that this was occurring on and off. The patient had no facial droop, no weakness in the upper or lower extremities, and was able to ambulate. The patient stated that weakness had a gradual onset, occurred intermittently, and was associated with extremity numbness. On physical examination, the patient's blood pressure was 194/78, with a pulse of 72, pulse oximetry at 99%, with a body mass index of 34.84. Physical exam findings were relatively unremarkable, except for documentation of sensory deficit in the left hand. The patient was given intravenous labetalol and was sent for imaging to include Computed Tomography (CT) of the head and Magnetic Resonance Imaging (MRI) of the brain along with laboratory testing. Repeat assessment noted blood pressure at 217/98 with a heart rate of 101. The remainder of her examination was unremarkable, and the patient was neurologically intact. The emergency department note stated that the Electrocardiogram was okay, all labs were okay, the chest x-ray was okay, with the CT scan and the MRI revealing no acute strokes. After a neurology consultation, the recommendation was to manage symptoms as a hypertensive emergency for blood pressure management. The goal was to get the systolic blood pressure below 180. The patient was admitted to neurology, with a notation that the blood pressure began to stabilize at 144/78 after receiving the 2 intravenous (IV) pushes of labetalol. The report indicated the blood pressure was well controlled. The patient remained inpatient until discharge. 

According to the Milliman Care Guidelines, admission for patients with a hypertensive emergency is indicated by systolic blood pressure greater than 180 or diastolic blood pressure greater than 120 with evidence of acute or worsening target organ damage as indicated by 1 or more the following to include hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine (new) from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, or other acute or worsening end organ damage due to severe hypertension. Alternatives to an admission include outpatient care in the emergency department, rapid treatment site, an urgent care center, or medical office for patients without progressing target organ damage. The information provided for the review noted that the patient presented to the emergency department with a history of hypertension, mitral valve prolapse, and a prior cerebrovascular accident with complaint of a 2-hour episode of numbness to the left side of the face and the left hand. The patient's symptoms had resolved when the patient came to the emergency department, all testing was negative for a cerebrovascular accident/stroke, and the patient responded favorably to intravenous labetalol to stabilize the blood pressure. Given these findings, the patient did not meet criteria for an inpatient admission. The patient could have had care rendered safely and effectively on an observational basis or an outpatient basis until the patient could be seen by the primary treating physician or cardiologist. The inpatient hospital admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.