Appeal type: Medical necessity
Decision: Upheld

This is a patient who was status post primary Cesarean delivery. She presented to the emergency department due to an elevated blood pressure at home and in her doctor's office. The patient stated that her prenatal course was uncomplicated in that she had no issues with her blood pressures during pregnancy. She reported being induced due to possible low amniotic fluid but she ended up with a Cesarean delivery due to non-reassuring fetal heart rate tracing. She went to her doctor's office for a postoperative check and was noted to have an elevated blood pressure of 145/90. She then went home and continued to monitor her blood pressures that were noted to be in the 130s to 140s over 100s with 1 episode of a 170 systolic blood pressure. She did not have any associated symptoms such as a headache, vision change or right upper quadrant pain. She had no increased swelling or nausea or vomiting. 

In the emergency department, her blood pressures were noted to be in the 140-150/90-100 range. Her obstetric history was noted for a full-term Cesarean delivery prior to admission due to nonreassuring fetal heart rate status. The patient had prenatal care with midwives. The gynecologic (GYN) history was negative. The patient reported no pain, vaginal discharge, menstrual changes or fever at admission. She was a G1 P1 at presentation. She had no past medical history. She reported a past surgical history for Cesarean delivery. The patient reported no smoking history or alcohol use. Her outpatient medications included Pepcid taken twice per day for heartburn. Her review of systems was otherwise negative. 

The patient was admitted with pregnancy-induced hypertension and was started on Procardia 30 extended release (XL). She was admitted for 23 hour observation for blood pressure monitoring and labs had been ordered and were normal. She was started on a regular diet and prenatal vitamins. She was to have sequential compression devices placed for deep vein thrombosis (DVT) prophylaxis. The patient was noted to have gestational or postpartum hypertension with normal lab results without severe symptoms and there was no indication for magnesium sulfate. She was started on Procardia and a plan was made for observation. 

The patient on hospital day 1 was noted to be evaluated and felt well that morning. She denied a headache, changes in vision, shortness of breath, chest pain, right upper quadrant pain and nausea and vomiting. She had no increased swelling in the extremities. She was tolerating a regular diet and ambulating without difficulty. Her lochia was minimal and she was voiding freely and having bowel movements (BMs) regularly. She was started on Procardia 60 milligrams (mg) XL yesterday for blood pressure control that had been increased from 30 XL per day. Blood pressures overnight were in the 110 to 120s over 60s to 80s and was now well controlled. She was stable and controlled on Procardia 60 XL daily and lab results were reviewed and were stable. The patient was cleared to discharge home with follow-up in the outpatient clinic. 

The health plan's determination is upheld. 

The patient presented with mild range hypertension in the postpartum setting without severe features. She was started on Procardia XL orally and her blood pressure was controlled and monitored. The patient was postpartum so there was no consideration of the pregnancy. There was no acute range blood pressure. The patient was noted to have mild range blood pressures without any hypertensive emergency. There was no evidence of end organ damage in this case. There was no evidence of a 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, the patient required oral antihypertensive therapy and given the lack of severe features, did not require magnesium. Given the absence of any change in her status and normal laboratory values with absent protein, there was no suspicion of preeclampsia in this case and this would not require treatment with magnesium sulfate. Thus, care in this case could have been provided at lower level than inpatient. There was no criterion met for admission to acute inpatient care in this case.