Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Hypertension/High Blood Pressure
Inpatient Hospital

The patient is a gravida (G)1 para (P)1 living (L)1 who presented to the hospital on postoperative day #10 after a low transverse cesarean delivery with chronic hypertension with concern for possible superimposed preeclampsia with severe features. The patient was readmitted with severe hypertension. She had previously been diagnosed with superimposed preeclampsia without severe features. The patient was now considered to have severe features based on her blood pressures. She was admitted for magnesium for seizure prophylaxis and the patient was planned to titrate antihypertensive medications as needed. There was also a plan to transition her to nifedipine for control of blood pressure. The patient reported that she had presented for an incision check at the outpatient clinic where she was noted to have severe range blood pressure as well as symptoms of intermittent headache and right upper quadrant pain. The patient was on labetalol 800 milligrams (mg) 3 times daily and reported being compliant with her dosing about two thirds of the time. On most days she reported taking 2 of 3 total doses. She reported her last dose had been taken at early morning. The patient stated she last had a headache as a migraine that was 2 days ago that responded to ibuprofen. She denied visual changes or abdominal pain but had tenderness in the right upper quadrant on examination in the office.

The patient's past medical history was noted for asthma, hypertension, and mental disorder, obesity, obstructive sleep apnea managed with continuous positive airway pressure (CPAP), and sciatica. The patient's surgical history includes colonoscopy and tonsillectomy. Her prior delivery was noted to be completed at 37 3/7 weeks gestation where she delivered a 2885 gram (g) male infant by cesarean delivery under epidural anesthesia. There were no other complications with her delivery reported. The patient's blood pressure at admission was 184/121 with a heart rate of 58. This was repeated around noon and noted to be 193/129 and then at 1125 was 138/66 after a single dose of oral nifedipine. The patient's weight was 184.6 kg or 407 pounds. She was 5 foot 2 inches.
The patient was admitted with a soft and nontender abdomen. The extremities were normal. Neurologic exam was noted to be normal. The heart rate was normal rate and rhythm. The lungs were clear to auscultation. The patient was obese and well-appearing. The patient was admitted to the hospital with concern for superimposed preeclampsia with severe features. This was based on worsening blood pressures in the setting of chronic hypertension. The patient had been intermittently compliant with labetalol and was given nifedipine 10 mg orally 1 for severe range blood pressure with good response. She had right upper quadrant tenderness and intermittent headache. A plan was made for IV magnesium sulfate for 24 hours for seizure prophylaxis. The patient was moved to the hospital room and was given Motrin for a mild headache. The patient was transitioned from oral labetalol to nifedipine and completed 24 hours of magnesium. She had no complications with magnesium during her 24 hour hospital stay. The patient's blood pressure was then managed in the mild range of 136/90, 141/88, 151/90 and 146/82. The patient had good urine output over the last 24 hours of 1200 cubic centimeter (cc). Her examination remained normal. The abdomen was appropriately tender and nondistended. There were positive bowel sounds.
The patient was planned for discharge to home with good blood pressure control. She was started on nifedipine 60 mg XL daily and had completed her IV magnesium sulfate. Labetalol was discontinued at that time. The patient was scheduled for a blood pressure check at a certain day after discharge. The patient was given this appointment for follow-up. She continued to have well-controlled blood pressures and was discharged. She was given appropriate precautions for follow-up.

The health plan's determination is upheld.

Based upon her review of the medical records in this case and the 22nd Edition Milliman Care Guidelines (MCG) Care Guidelines entitled "Hypertensive Disorders of Pregnancy", there would be no medical necessity for acute inpatient care based upon these guidelines and the peer reviewed literature when reviewed in concert with the records. In this case, the patient presented with headache and postpartum chronic hypertension with poor compliance with her oral Labetalol. She was given oral nifedipine with control of blood pressure achieved and monitored. The patient was given 24 hours of magnesium for seizure prophylaxis. There was no persisting acute range blood pressure after treatment with the single dose of nifedipine. The patient was noted to have mild range blood pressures without any hypertensive emergency for the remainder of the hospitalization. There was no evidence of end organ damage in this case. There was no evidence of cerebral infarction or intracerebral hemorrhage. There was no evidence of vision loss or unstable angina. The patient had no history or symptoms suggesting myocardial infarction, pulmonary edema, aortic dissection, seizures, or acute renal failure. The patient was noted to have normal renal function as measured by her creatinine and had a normal physical exam with normal neurologic exam. There is no evidence of intracranial abnormality or indication for imaging.
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. A neurologic exam was also normal. There were no seizures present. Fetal status was not considered as she had been delivered 10 days prior by cesarean. Based upon this information, the patient would not meet criteria for acute inpatient admission.