Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Preeclampsia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a patient who is gravida (G) 2 para (P) 0 abortus (A) 1 who presented to the obstetrics (OB) triage from an outpatient office with elevated blood pressures and complaints of a headache that had resolved. The patient had a history of migraine headaches. She denied right upper quadrant (RUQ) pain, epigastric pain, nausea or vomiting, shortness of breath or chest pain. The patient was noted to have a diagnosis of chronic hypertension on Labetalol 300 milligrams (mg) twice daily (BID) but was inconsistent with compliance with this medication. She had a prior termination of pregnancy. She had no prior surgical history. She was noted to have reassuring fetal testing by nonstress test (NST) and underwent an ultrasound at the bedside with a normal amniotic fluid index (AFI) of 15.8 centimeters(cm) and normal fetal weight of 1020 grams (g) by ultrasound. The patient was assessed to have chronic hypertension with superimposed preeclampsia with severe features by blood pressure which was 180/98 at presentation. She was noted to have a normal closed and long cervix. She was given intravenous (IV) labetalol in triage times (x) 2 with both 20 milligrams (mg) and 40 mg IV. She was started on magnesium sulfate and a 24 hour urine was started.
She was admitted to labor and delivery (L&D) for management. Labs were planned every 8 hours with magnesium checks. The patient signed out against medical advice (AMA) after being counseled on the risks of her condition and benefits of management in the hospital given her condition. Followup was scheduled with both maternal fetal medicine and her primary obstetrician on the following day in the outpatient setting. Her biophysical profile (BPP) was reassuring on the fetus at 10/10 prior to discharge AMA. The patient was noted to deny headaches and had no shortness of breath, nausea or vomiting, or vision change. There was no right upper quadrant (RUQ) pain or epigastric pain.  There was no evidence of HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome. A review of the blood pressures noted the patient to have blood pressures. At issue is the medical necessity of an inpatient stay.
Based upon a review of the medical records and the Milliman Care Guideline (MCG) Inpatient & Surgical Care 24th Edition, Hypertensive Disorders of Pregnancy, acute inpatient level of care was medically necessary due to the blood pressures that this patient experienced in the severe range and the specified criteria for admission to acute inpatient stay. The MCG guideline allows for admission for patients with preeclampsia, chronic hypertension or gestational hypertension when the blood pressure is severe (systolic blood pressure greater than or equal to 160 millimeters of mercury (mmHg) or diastolic blood pressure greater than or equal to 110 mmHg. In this case, the patient presented with a severe range blood pressure of 180/98 as a patient with chronic hypertension now suspected of superimposed preeclampsia with severe features based upon her blood pressure. This was treated with intravenous (IV) Labetalol on top of her usual 300 mg Labetalol orally twice per day. Her blood pressures continued in the severe range. Thus, the patient met medical necessity for admission to acute inpatient level of care based upon a review of her chart and the MCG Guideline.