Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with a history that includes uncontrolled hypertension, hypothyroidism, and chronic substance use. The patient presented with a year of periorbital swelling, high blood pressure, and neck pain. She had not taken medications for a year. The patient's blood pressure in the emergency room was 161/131. The patient was treated with labetalol and Lisinopril and was admitted. Chest x-ray revealed no acute disease. Pertinent labs included: troponins 28 and 37, hemoglobin 12.8, creatine phosphokinase (CPK) 1058, creatinine 0.94, sodium 135, potassium 3.1, brain natriuretic peptide (BNP) 118, thyroid stimulating hormone (TSH) 257, and magnesium 1.5. Vital signs at the time of admission were stable. The patient's blood pressure was 135/72. Head computed tomography (CT) revealed no acute disease. Exam showed periorbital edema, mild epigastric tenderness, and erythema of shins. The plan included amlodipine, trend troponin, replete electrolytes, and Endocrinology consult. On day #2, the patient's vital signs were stable. The patient was receiving intravenous potassium. Endocrinology recommend oral Synthroid. Gastroenterology recommended magnetic resonance cholangiopancreatography and magnetic resonance image. On day #3, magnetic resonance cholangiopancreatography (MRCP) negative for a stone. A 
hepatobiliary iminodiacetic acid (HIDA) and magnetic resonance image were recommended. The patient was on a clear liquid diet. Her current medications were continued. On day #4, hepatobiliary iminodiacetic acid scan was performed and unremarkable. On day #5, there were complaints of back and abdominal pain; OxyContin was not working. Magnetic resonance image was pending. On day #7, magnetic resonance image was reported as negative. The patient was discharged.

The requested health service was not medically necessary. 

The patient presented with uncontrolled hypertension with a blood pressure of 161/131 due to medication noncompliance. She responded to treatment in the emergency department with blood pressure normalizing to 135/72. Diagnostic studies did not show end organ damage. In addition, the patient had abdominal pain and suspected gallbladder disease. The patient did not have severe abdominal pain and was able to tolerate oral intake. 
The Milliman Care Guidelines criteria for Hypertension are not met. The patient did not have target organ damage with hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, or seizure.
The Milliman Care Guidelines criteria for Abdominal Pain, Undiagnosed are not met. The patient was hemodynamically stable. She did not have severe pain requiring acute inpatient management. The patient did not have peritoneal signs, evaluation that requires patient to not eat or drink for extended period, inability to maintain oral hydration, suspected toxic megacolon, bacteremia, or identification of etiology or finding that requires inpatient care.