Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Inpatient stay
The insurer denied: Inpatient stay
The denial is upheld

This adult female was hospitalized for hypertension. She presented to the ED (emergency department) for evaluation of headache with visual changes and elevated blood pressure. Her past medical history is significant for known hypertension, end-stage renal disease on hemodialysis and morbid obesity. Her BP (blood pressure) was initially 203/112 mmHg (millimeters of mercury) followed by 198/98. Chest x-ray and head CT (computed tomography) revealed no acute abnormalities. Her potassium was elevated to 6.3, but there was moderate hemolysis and her troponins were negative. Treatment included IV (intravenous) Labetalol 10 mg (milligrams), followed by oral antihypertensive medications. A performed echocardiogram revealed severe concentric LVH (left ventricular hypertrophy) and low but normal LVEF (left ventricular ejection fraction) of 50-55% (percent). The clinical impression was hypertensive urgency. The patient's blood pressure readings improved, and the patient was cleared for discharge. This is an appeal of the denied claim for the requested acute inpatient hospital stay, and determination on whether it was medically necessary for this patient.

The proposed treatment of an inpatient stay is not considered medically necessary. 

The requested acute inpatient hospital stay is not considered 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. Criteria for inpatient hospital stay are not met, including documentation of hypertensive emergency with evidence of acute and progressing target organ disease, such as, hypertensive encephalopathy/altered mental status, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure with pulmonary edema, aortic dissection, increased creatinine (new) with reduction of more than 50% (percent) in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, other significant finding secondary to hypertension, adrenergic or sympathomimetic crisis (such as severe hypertension due to pheochromocytoma crisis), cocaine, phencyclidine, or amphetamine intoxication or clonidine withdrawal, severe hypertension a SBP (systolic blood pressure) greater than 180 mm Hg or a DBP (diastolic blood pressure) greater than 110 mm Hg) that cannot be controlled (e.g., to systolic blood pressure less than 160 mm Hg and diastolic blood pressure less than 100 mm Hg in adults) by emergency department or observation care treatment. There was no clinical decline or inadequate response to treatment which required inpatient hospitalization. The care this patient received, including management of uncomplicated hypertensive urgency and non-hypertensive emergency (as in this case) is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published guidelines, the proposed treatment, acute inpatient hospitalization is not considered "medically necessary".