Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems/Hypertension/high blood pressure
Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is overturned.

This patient is under consideration for the medical necessity of admission to acute inpatient level of care. This patient is a female Gravida3Para3, who presented at 7 days postpartum with elevated blood pressures at home. The patient was postpartum from a vaginal delivery. The patient presented to the Emergency Room and was noted in triage to have a blood pressure of 191/89 millimeters of mercury (mmHg), with pain of 7/10 that started 3 hours ago. The patient reported a blood pressure at home of 170/94 mmHg. She reported pain in the back of her head. She had a normal neuro exam. She was to be admitted for medical management, given acute hypertension in the postpartum state. The patient had no history of hypertension or preeclampsia during pregnancy. She had no past medical history. She was a smoker. She was noted to have an elevated lactate dehydrogenase (LDH) and uric acid. She was to be treated with Labetalol. She was to get Magnesium Sulfate and was admitted to Obstetrics/Gynecology. She denied vision changes, right upper quadrant pain or epigastric pain. She had received Labetalol 10 milligrams (mg) intravenous (IV) x 2 doses in the emergency room (ER). The patient also had repeat blood pressures in the 180's mmHg and was given Hydralazine 10 mg and Procardia 10 mg immediate release. She was noted to have a heart rate in the 50's beats per minute (bpm) and Hydralazine was opted for in further management of the hypertension. Magnesium Sulfate was ordered for seizure prophylaxis, given this was postpartum preeclampsia with severe hypertension (severe features). Labs noted a uric acid of 9.1 with an LDH of 513. Aspartate aminotransferase (AST) was normal at 28 with an elevation of alanine aminotransferase (ALT) at 58. The patient was also ordered for Procardia XL 30 mg every day.

I would overturn, in whole, the health plan's determination of medical necessity in this case.

Based upon a review of the medical records and the Milliman Care Guidelines (MCG) Health Inpatient &amp; Surgical Care 26th Edition (Anthem) Hypertensive Disorders of Pregnancy Guideline, the requested admission to acute inpatient level of care would be considered medically necessary.

In this case, the patient is noted to be presenting with severe range hypertension to the ER and with reports of the same in the ambulatory setting. She was noted to have severe occipital headache and blood pressures that were in excess of 160 systolic mmHg at presentation. These required treatment with multiple doses of IV Labetalol and Hydralazine and then Procardia XL ongoing. She then would have abnormal labs with elevation of LDH and uric acid with ALT elevation and was indicated appropriately for Magnesium Sulfate. This was administered for 24 hours. Given this patient had severe range hypertension and then persisting hypertension, there was medical necessity for admission and acute inpatient level of care for this period for postpartum preeclampsia with severe features. This is approved by MCG on the admission and for extended stay due to persistent hypertension with escalation of antihypertensive therapy (increased Procardia). This decision is in agreement with the recommendations of American College of Obstetricians and Gynecologists (ACOG).