Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated blood pressure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) after she was seen in her doctor's office and referred to the ED because of an elevated blood pressure. In the office, her blood pressure (BP) was noted as 290 and she had a mild headache. The patient had a history of hypertension (HTN), obesity and a history of a hysterectomy. Her HTN was long standing.
Her vital signs in the ED revealed a BP of 200/122, heart rate (HR) 79 beats per minute (BPM), normal temperature and oxygen saturation (O2 sat) of 97% on room air (RA). Her body mass index (BMI) was 39.09. Her physical examination was unremarkable. Her potassium was 3.2 and her troponin was 0.03. Her white blood cell count (WBC) was 12.7. She has an abnormal electrocardiogram (ECG). The patient was given intravenous (IV) hydralazine, potassium. She also received oral acetaminophen. The patient was admitted to the telemetry unit for BP monitoring, potassium monitoring. She was given oral medications. Her serial troponin was 0.03, 0.05 and 0.04.
Her potassium was 3.1. The potassium was replaced and hydrochlorothiazide (HCTZ) was added to the BP regimen, because her BP was above 150 systolic.
Her echocardiogram was completed and it revealed moderate LVH with an ejection fraction (EF) of 66-70%. There was grade I diastolic dysfunction. There was moderate left atrial dilatation. The right atrium and right ventricle were normal. There was mild tricuspid and mitral regurgitation.
Her condition remained stable; she did not have any cardiac complaints. Her troponin elevation was felt to be due to demand ischemia. Her potassium was 3.4. The patient also was diagnosed with depression and anxiety and started on low dose of venlafaxine.
The patient was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient was found to have very high BP in the doctor's office and was sent to the ED. She was found to have a high BP, low potassium, slightly elevated troponin and abnormal electrocardiogram (ECG). Her symptoms of an elevated BP were mild, only a mild headache. There was no evidence of complications of hypertension, such as acute coronary syndromes, stroke, or pulmonary edema,
It was appropriate to monitor the patient for 24 hours to repeat the troponin, replace the potassium and control her BP. Her potassium was rechecked only the next day. It could have been checked 8 hours after replacement, which would expedite the patient's management. Her serial troponin was only mild elevated, most likely due to elevated BP. The patient did not need to stay for 2 nights. Her potassium could have been managed in a more expedited manner, during or less than 24 hours. She could have been discharged the next day after staying at the hospital. Her BP went down with oral medications, and she was asymptomatic. Her echocardiogram was unremarkable. An inpatient level of care was not medically necessary. Care could have been provided at a lower level.
Per the first reference: "A rapid, marked and persistent rise in blood pressure (BP) levels above 180/120 millimeters of mercury (mmHg) is a clinical condition currently defined as hypertensive emergency or urgency in the presence or absence of acute signs of hypertension-mediated organ damage, respectively [1]. 
Beyond the magnitude of BP rise and absolute BP levels, early recognition of these conditions is crucial from both a prognostic and a therapeutic point of view. Current European guidelines recommend clinical observation with repeated BP measurements and gradual BP reductions throughout the administration of oral antihypertensive drug therapies in individuals with hypertensive urgencies [2]. On the other hand, patients with hypertensive emergencies should immediately receive pharmacological and nonpharmacological interventions for lowering BP levels, mostly through the administration of intravenous drugs, and undergo specific treatment protocols for the clinical management of associated clinical conditions, such as acute coronary syndromes, stroke, pulmonary edema, eclampsia, and aortic dissection [2]. Similar recommendations have been issued by the United States guidelines on hypertension [3].