Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Hypertension

Treatment inpatient emergency

The insurer denied coverage for inpatient emergency	

The denial is upheld

The patient is a female 34 weeks and 2 days of gestation with a history of chronic hypertension. She presented to the hospital from the Maternal Fetal Medicine (MFM) office with complaints of elevated blood pressure. On arrival, blood pressures were between 150-160s/90-100s. Pregnancy induced hypertension (PIH) labs were within normal limits (WNL). Betamethasone was given. The patient was admitted and monitored overnight. By the next day, blood pressures returned to a normal range. She was discharged with instructions to follow up with the Obstetrician and MFM specialist on an outpatient basis. 

According to the medical records, the patient was admitted for the following reasons:
Pregnancy induced hypertension evaluation, betamethasone administration and monitoring of blood pressure.

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 mm Hg (millimeters of mercury) or higher, or diastolic blood pressure of 110 mm Hg or higher) should be diagnosed with preeclampsia with severe features. These severe ranges of blood pressure increase the risk of morbidity and mortality.  According to American College of Obstetricians and Gynecologists (ACOG), ambulatory management at home is an option only for women with gestational hypertension or preeclampsia without severe features and requires frequent fetal and maternal evaluation. Hospitalization is appropriate for women with severe features. This patient did not have preeclampsia.
Note that betamethasone administration does not require hospital admission.

Please note that neither the patient nor the fetus were in any jeopardy. Fetal heart rate was reassuring. There was no evidence of ruptured membranes.

Milliman Care Guidelines (MCG) list the following clinical indication for admission:

. 	Condition requiring premature delivery
. 	Delivery
. 	Fetal distress or demise
. 	Preterm labor and positive fFN [Fetal fibronectin (fFN)]
. 	Significant maternal disease, infection or comorbidity as cause
. 	Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete.
. 	Continued fetal monitoring
. 	Tocolytric therapy that requires inpatient care
. 	Complications of tocolytic treatment

This patient did not have any of the above. She is known to have chronic hypertension. She could have been observed in labor and delivery. Once preeclampsia was ruled out, she could have been discharged to be followed up and tested as an outpatient. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient emergency admission is not considered medically necessary for this patient. 

The insurer's denial of coverage for the inpatient emergency is upheld. Medical Necessity is not substantiated.