Appeal type: Medical necessity
Decision: Upheld

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


The patient was admitted to the hospital with an admission diagnosis of preeclampsia in the third trimester and hypertension affecting pregnancy and antepartum setting. The patient was noted to have a prior history of a stroke with no residual effects. She had been taking a baby aspirin daily given her history. She also had a prior history of 2 prior Cesarean deliveries and right ovarian removal at the time of one of the Cesarean deliveries. She also had a previous suction dilation curettage performed  due to an incomplete abortion. The patient was a social cigarette smoker. She had quit smoking in 2015 but had a use of 2 years total duration. The patient denied any drug use or alcohol use.
The patient's medications at admission included aspirin 81 milligrams (mg), iron sulfate 325 mg and a prenatal vitamin daily. The patient was noted to have a past medical history of gravida (G) 3 para (P) 2, preeclampsia, stroke, hypertension and a past surgical history as listed with complaints of intermittent, moderate headache since the day prior. She admitted to associated nausea and dizziness.
The patient reported that she had called her obstetrician and was told to present to the emergency department. The patient reported that the symptoms were similar to her last episode of preeclampsia. She denied a fever, chills, chest pain, leg swelling, a cough, shortness of breath, vomiting, abdominal pain, diarrhea, dysuria, hematuria or tingling. The patient was triaged and the obstetrician was immediately paged. The patient's review of systems was noted to be positive for nausea but negative for abdominal pain, diarrhea or vomiting.
She reported positive dizziness and headaches but no tingling. At admission, her blood pressure was 178/104 with a heart rate of 104 and temperature 98.1 degrees Fahrenheit. Respirations were 20 and her oxygen saturation was 98% on room air. The patient's physical exam was documented to be normal. Her white blood cell count was 8.2 with a hemoglobin of 9.4 and hematocrit 28.9%. Platelets were normal at 193. The patient also had a normal differential. An electrocardiogram (EKG) was performed and was noted to be normal. The patient underwent an ultrasound which noted a positive fetal heart rate. She was hemodynamically stable and was then discharged to go to the obstetrical unit. An electrocardiogram (EKG) was read as normal. The urinalysis was noted to be negative for protein. The patient had normal uric acid of 3.8. Liver functions were noted to be normal. Coagulation studies were normal. The patient underwent a formal biophysical profile scoring which was reassuring at 8 of 8. The amniotic fluid index was 14.6 centimeters (cm) with the largest vertical pocket 6.3 cm. The baby weighed 2319 grams (g) and the cervix was 4 cm long. Cardiac activity was documented 143 beats per minute (bpm). The patient was given a dose of labetalol 10 mg intravenous (IV) in the emergency department and was also started on magnesium sulfate with a 4 g load and 2 g per hour for possible preeclampsia. The patient's repeat blood pressure after admission approximately 20 minutes later at 16:05 p.m. was 133/84 and normal. This had decreased from the prior blood pressure 178/104.

The patient reported that her blood pressure was elevated at home at 150/100 with a mild headache for 2 days and vision changes earlier that day. She was evaluated in the emergency department first and her blood pressure was 178/104 on admission and she received labetalol 10 mg IV  and was started on magnesium. During her admission, the patient's blood pressures were stable to 140s over 70s to 80s. The patient had a past medical history of chronic hypertension. At admission, her blood pressure was 141/80. She remained afebrile and her heart rate was 96. Respiratory rate was 22. Her examination was noted to be benign. The extremities were normal without edema. Her cervix was closed, long and posterior. The fetal heart rate was 150s with moderate variability and no decelerations. There were occasional contractions noted and the fetus was in a cephalic presentation. The patient was GBS unknown. Blood type was A positive (+). Her rapid plasma reagin (RPR) was nonreactive. Glucola was 202 followed by 3 hour glucose tolerance test of 97, 98, 189, 204, 131. Gen-Probe was negative. Hepatitis B was also negative. A panorama was performed and was low risk for fetal chromosome abnormalities. The patient had a negative quantity or on an negative human immunodeficiency virus (HIV). Her rubella was immune. The last maternal-fetal medicine visit noted an estimated fetal weight of 2045 g at the 64th percentile. The biophysical profile performed at admission was 8 of 8 and reassuring. The patient's assessment was that she had uncontrolled chronic hypertension and being evaluated for preeclampsia. She had one severe range blood pressure with the remainder of her blood pressures being normal. She had received 1 dose of IV Benadryl for her for her iron deficiency anemia. The patient recently complained of a mild headache and vision changes earlier on the day of admission but was currently reporting asymptomatic status. She had no headache or vision changes reported. The plan was to admit her for betamethasone and monitoring of her blood pressure at 15 minutes. She was then started on labetalol 200 mg 3 times daily with a plan of continued magnesium for seizure prophylaxis for 24 hours during this evaluation. The patient had monitoring of her blood glucose. She also had sequential compression devices (SCDs) placed for deep vein thrombosis (DVT) prophylaxis. Labs were planned every 12 hours to ensure no change. The patient was to be monitored closely.
The patient was noted to have no complaints of vaginal bleeding, rupture of membranes and admitted to positive fetal movement. She had occasional contractions overnight. She was on oral labetalol and Procardia for blood pressure management and her Celestone had been completed with her first dose. Her blood pressures had been maintained in the normal range. The patient's exam was benign. Her labs remained stable. A protein to creatinine ratio was noted to be normal. The patient was to continue magnesium for 24 hours with discontinuation. Her second dose of Celestone was planned and she was to continue labetalol 100 mg twice daily and continue on diabetic diet. The plan was possible for discharge in the morning if she remained stable.
The patient was discharged to home with follow-up in the outpatient setting. Blood pressures remained stable on labetalol. At issue is the medical necessity of an inpatient stay.
Based upon as review of the medical records in this case and the 22nd Edition Milliman Care Guidelines (MCG) entitled "Hypertensive Disorders of Pregnancy", the acute inpatient care was not medically necessary.The patient presented with headache and chronic hypertension with one elevated blood pressure and negative protein. She was given a course of steroids and monitored. Fetal status was reassuring by both fetal monitoring and biophysical profile (BPP) of 8/8. There was no persisting acute range blood pressure after admission and this was controlled in the ER with a single dose of 10 mg of Labetalol. 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 (0.59) and had a normal physical exam with normal neurologic exam. There is no evidence of intracranial abnormality or indication for imaging.
In consideration for admission to the acute inpatient care, the MCG guideline would recommend admission as medically necessary for eclampsia, planned delivery, severe preeclampsia with new onset seizures and hypertension with acute end organ damage as indicated by one or more of the following: hypertensive encephalopathy, cerebral infarction, intracerebral hemorrhage, visual loss, unstable angina, myocardial infarction, acute pulmonary edema, aortic dissection, seizures, or acute renal failure. In this case, all of these findings were absent and lab testing was normal. A neurologic exam was also normal. There were no seizures present. Fetal status remained reassuring. Based upon this information, the patient would not meet criteria for acute inpatient admission. Care could have been provided at a lower level.. The patient required antihypertensive therapy for chronic hypertension and magnesium for completion of her workup. Given the absence of any change in her status and normal laboratory values with a negative protein, there was no suspicion of preeclampsia in this case and this would not require ongoing treatment with magnesium sulfate beyond 24 hours. There was no criterion met for admission to acute inpatient care in this case.