Appeal type: Medical necessity
Decision: Upheld

Hypertension
Inpatient hospital stay

The patient is  G7P7A0L7 who was status post prior cesarean delivery and presented with hypertension of 189/104 with repeat blood pressure of 165/109. She denied headache, visual disturbance, or right upper quadrant (RUQ)/epigastric pain. She was noted to have a prior history for preeclampsia with delivery and was told she had preeclampsia. However, she did not receive magnesium for seizure prophylaxis and was started on Labetalol 400 milligrams (mg) twice daily (BID) that she had self-discontinued. Blood pressures and labs were stable at discharge from her prior delivery. Her oxygen saturation was normal on room air. She had no chest pain, palpitations, shortness of breath, calf pain or other problems reported. At admission, after receiving 20 mg of intravenous  Labetalol, the patient was noted to have a blood pressure of 132/91. The heart rate was 73. She had 97% oxygenation on room air. She was noted to be asymptomatic with an unremarkable physical exam that was normal. She had normal deep tendon reflexes. The plan was to check preeclampsia labs and start magnesium for seizure prophylaxis.  The patient completed magnesium prophylaxis and was without complaints. She was discharged to home with outpatient follow-up scheduled. She was placed on Labetalol 300 mg three times per day (TID) for hypertension. The health plan's determination is upheld in whole.The medical records were reviewed in concert with the MCG Guideline entitled "Hypertensive Disorders of Pregnancy". These guidelines support admission to inpatient care if the criteria are met. In this case, the patient did not meet any of the criteria. The patient was hypertensive and off her medications for chronic hypertension. Thus, preeclampsia was not a consideration. The peer reviewed literature was also examined in this case given this is a patient with a remote history of preeclampsia that was under treatment for chronic hypertension at discharge but with a noncompliant patient with her antihypertensive regimen.  "Delivery does not immediately reverse the pathophysiologic changes of preeclampsia, and it is necessary to continue palliative therapy for various periods. Some of the constraints on therapy, however, are eliminated by delivery of the fetus. Hypertension may take considerably longer than 24 to 48 hours to resolve. Women who are hypertensive 6 weeks after delivery may be normotensive at long-term follow-up. The indications for therapy are similar to those for the antepartum period. The patient with blood pressure greater than 160 mm Hg systolic or 105 mm Hg diastolic after delivery should be treated; the fetus no longer influences therapeutic choices. If rapid blood pressure control is necessary, sodium nitroprusside is more effective and better tolerated than hydralazine. Diuretics and conventional oral antihypertensive agents can be started to achieve smooth control. The woman who remains hypertensive (>100 mm Hg diastolic pressure) should be sent home with continued antihypertensive therapy.. The choice of drugs is based on the usual step method of antihypertensive therapy. The patient sent home with a therapeutic regimen must be warned about symptoms of hypotension, and she must be seen at weekly intervals, because the need for therapy diminishes rapidly in some cases."The woman who remains hypertensive (>100 mm Hg diastolic pressure) should be sent home with continued antihypertensive therapy." This patient was noted to have blood pressures that were elevated based upon these recommendations. Thus, her control was optimized with restarting her oral antihypertensive regimen (Labetalol) that she had self-discontinued. The blood pressure was readily controlled on oral medications and the patient was discharged to home. This care would not require acute inpatient care for restarting her blood pressure medications in the state of chronic hypertension. According to MCG, this care could be provided at a lower level of care.