Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems- Hypertension/High Blood Pressure
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient was directed to the emergency department with concerns of hypertension. Review of symptoms were negative for headache, dizziness, blurred vision, or neurological deficits. History included non-compliance, hypertension, chronic kidney disease, baseline serum creatinine approximately 4, chronic anemia, human immunodeficiency virus, and cirrhosis. Initial blood pressure 192/79. Initial examination  without neurological deficits. Serology revealed blood urea nitrogen (BUN) 79, Creatinine 9.1, carbon dioxide  9.6, sodium(Na) 139, potassium 4.4, Glucose 96, Lipase 71, Troponin I 0.040.  A repeat Troponin was 0.034. An electrocardiogram noted non-specific T wave inversions and repeat did not reveal any acute ischemic changes. Nifedipine and intravenous labetalol were provided with an improvement of systolic blood pressure to 140. Treatment plan included oral anti-hypertensives, oral sodium bicarbonate, and nephrology consultation. 
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Rodriguez et al. discussed the evaluation and management of a Hypertensive crisis. They note that an uncontrolled hypertension can progress to a hypertensive crisis defined as a systolic blood pressure >180 or a diastolic blood pressure >120. Hypertensive crisis can be further classified as a hypertensive urgency or hypertensive emergency depending on end-organ involvement including cardiac, renal, and neurologic injury. The prompt recognition of a hypertensive emergency with the appropriate diagnostic tests and triage will lead to the adequate reduction of blood pressure, ameliorating the incidence of fatal outcomes. [1] In this particular situation, the patient met criteria for a Hypertensive crisis. To go a step a further, they then met the subset criteria for the diagnosis of Hypertensive urgency.
Kessler et al. published guidelines regarding the evaluation and management of severe asymptomatic hypertension. They define severely elevated blood pressure as 180 or greater systolic, or 110 or greater diastolic. Severely elevated blood pressure can be classified as severe asymptomatic hypertension or hypertensive emergency. Severe asymptomatic hypertension is defined as severely elevated blood pressure without signs or symptoms of end-organ damage. Hypertensive emergency (sometimes called hypertensive crisis) is the point when signs or symptoms of end-organ damage occur. Hypertensive urgency is defined as the presence of risk factors for progressive end-organ damage, whereas severe uncontrolled hypertension is defined as the absence of these risk factors.[2] In this particular situation, the patient would be classified as Hypertensive urgency given the risk factors for progressive end-organ damage.
The patient did not have hypertensive encephalopathy that persisted past the emergency department, cerebral infarction, intracranial hemorrhage, myocardial infarction, decompensated congestive heart failure, aortic dissection, increased creatinine with reduction of more than 50% in estimated glomerular filtration rate from baseline, (Nephrology consultation recommendations stated no acute need for renal replacement therapy. The patient was deemed medically stable for discharge to home with a serum creatinine greater than 9.) papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, or other significant finding secondary to hypertension. The patient also did not have severe hypertension that could not be controlled by emergency department or observation care treatment.[3]