Appeal type: Medical necessity
Decision: Upheld

Diagnosis: high blood pressure with pregnancy
Treatment: Inpatient admission
The health plan denied the requested inpatient admission as not medically necessary.
The health plan's determination is upheld.

This patient is under consideration for admission to acute inpatient level of care. In this case, the patient was a female Gravida1Para0 who presented at 24-3/7 weeks gestation. The patient was sent to labor and delivery (L&D) for evaluation of possible superimposed preeclampsia upon chronic hypertension. The patient was on Nifedipine 30 XL (extended release) and had taken this at 8AM. She reported that she had been monitoring her blood pressure (BP) at home and this was usually in the 120's millimeters of mercury (mmHg) over 70's/mmHg. She had no headaches, vision changes, dyspnea or swelling. She was noted to also have gestational diabetes, possible superimposed preeclampsia on chronic hypertension with a urine protein of 308. This was her first pregnancy. She had no prior surgeries and was on folic acid, prenatal vitamin, and Nifedipine. She had allergy to aspirin. She had a prior history of smoking for a 19 pack year history but quit with this pregnancy. The patient had a HemoglobinA1c of 5.9%. Rubella was immune. The platelets were normal at 297. Ultrasound was noted for a 498-gram fetus at 22 weeks. Review of systems was negative. The patient's vitals were a weight of 94.3 kilograms (kg). She had a blood pressure of 137/76 mmHg at presentation. She had a normal exam. Ultrasound was repeated and the estimated a fetal weight of 747 grams. The fetal monitoring was reassuring with moderate variability, positive access, no decelerations. A blood glucose was 150 in triage. She had two severe range blood pressures in triage, but this was not persistent. The plan was made to increase the Nifedipine to 60 milligrams (mg) every day in the morning since she remained stable without ongoing hypertension. 

The health plan's determination of medical necessity is upheld, in whole.

In this case, the patient presented with known chronic hypertension and was under consideration for superimposed preeclampsia. However, she did not have sustained elevated blood pressures and was suspected to have poorly controlled chronic hypertension. She was not given a course of steroids as delivery was not indicated or even suspected. Fetal status was reassuring on monitoring and an ultrasound noted normal fetal growth. There was no acute range blood pressure that was sustained and the blood pressure recorded at admission was normal. The patient was noted to have mild range blood pressures without any hypertensive emergency ongoing. It 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 this case, there were no severe, acute range hypertension that was ongoing and management at an alternate level of care would have been appropriate for care.  There was no end-organ damage by labs.  Thus, an alternate level of care would have been appropriate in this case. [5]