Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld in whole. 

The patient is a male with a past medical history significant for cystic fibrosis, asthma, type 2 diabetes mellitus, hypertension, and chronic kidney disease who presented to the emergency department with complaints of intermittent headache, blurry vision, and dizziness. The patient denied chest pain, palpitations, shortness of breath.
At the time of the initial evaluation in the emergency department, the patient was found to be hypertensive and received treatment with intravenous antihypertensive medications.
When the patient was seen by the admitting physician, his headache and blurry vision resolved. He was still complaining of fatigue.
At the time of admission, the patient was afebrile, his heart rate was 76 beats per minute (bpm), respiratory rate 17, and blood pressure 150/109.
The patient was admitted to the hospital with uncontrolled hypertension. It was mentioned that the patient had elevated troponin. At the same time, the admitting physician suggested that mild elevation of the troponin was likely related to chronic kidney disease. Apparently, the patient had a minimally elevated creatinine level over the baseline.
During the hospital stay, all of the patient's symptoms resolved, and the patient was deemed stable for discharge. The patient was discharged home in the stable clinical condition the next day after the day of admission.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient hospital stay was not medically necessary for this patient.
The review of the medical records demonstrated that the patient likely had hypertensive urgency and not an emergency. The blood pressure documented in the note from the emergency room (ER) provider was 151/94. On another measurement, the patient's blood pressure was 160/110. At these levels, it was unlikely that the patient had a hypertensive emergency.
According to the accepted standards of care, a hypertensive emergency is usually defined as a systolic blood pressure greater than 180 millimeters of mercury (mmHg) or diastolic blood pressure greater than 120 mmHg with evidence of acute or worsening target organ damage such as hypertensive encephalopathy (altered mental status), cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine with reduction of more than 50% in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, or some other circumstances not relevant to this clinical case.
The review of the medical records clearly demonstrated that the patient had none of these circumstances. Even if he had some neurologic symptoms at the time of the initial presentation to the emergency department, these symptoms resolved by the time the patient was seen by the admitting physician.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient stay. The patient could have been managed at a lower level of care status.