Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy/Childbirth - Preeclampsia 
Treatment: Inpatient Hospital 

The insurer denied the inpatient hospital stay. The denial was overturned. 

The patient is a female who was admitted to the hospital for postpartum preeclampsia. She was admitted three days after a routine vaginal delivery when she presented with severe headache and blood pressure as high as 170's/110's. She required intravenous antihypertensives and magnesium seizure prophylaxis. During her stay, she also had a fever of unclear etiology and was treated with ceftriaxone. Abdominal pain developed on her second day in-house, with a work-up finding an ileus. Both the hypertension and the ileus improved on hospital day 3, and the patient was discharged with outpatient follow-up. 

An inpatient level of care was medically necessary in this case. Postpartum preeclampsia is a highly dangerous condition that even in the postpartum setting can lead to seizure or cerebrovascular accident. Control of hypertension is essential, and difficult to establish outside the hospital without the benefit of monitoring. This patient required IV medication upon admission. Even the later utilized oral medications must be started and adjusted while the patient is hospitalized because of the hazard of causing hypotension (unlike essential hypertension, the hypertension of preeclampsia is often highly labile and therefore offers an unpredictable response to medication). Observation status refers to interventions that could be accomplished in an outpatient or emergency setting. Magnesium sulfate administration, essential in this case, does not fit that criteria. Intravenous magnesium is considered a high-risk medication and requires intensive monitoring by nursing staff. Clinical evaluations at least every 30 minutes are standard to monitor for toxicity. The FDA labeling for the drug magnesium sulfate is specific about intensive monitoring including tracking of urine output. 

The patient presented with a life-threatening condition requiring a high level of inpatient care. The physician treating a postpartum preeclamptic patient is obligated to control blood pressure while preventing seizure or other poor outcome. Neither of those is appropriate in an outpatient or observation setting because preeclampsia varies wildly between patients and can harm the patient in so many different ways: seizure, CVA, MI, pulmonary edema, liver failure, and renal failure. Hypertensive disease of pregnancy remains the third most common cause of maternal death. Recent highly publicized efforts at reducing maternal mortality have called for more aggressive action of patients presenting with preeclampsia. Treatment of postpartum preeclampsia requires rapidly changing medications and a high level of nursing intervention because a life-threatening seizure can occur anytime. These patients are usually even kept in beds with pads on the side-rails, and restricted from ambulation - again, not possible as an outpatient. Magnesium, used to prevent seizures, requires intensive monitoring and nursing intervention in itself. The perilous risks of postpartum preeclampsia were treated with an appropriate level of concern in this case. The patient required two days to improve blood pressures and assure she was safe for discharge to home without risk of seizure or cerebrovascular accident. On top of all of this, this patient also had a fever and ileus - two more complications of delivery that demanded work-up and treatment. An inpatient level of care was medically necessary.