Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and Dizziness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult female was hospitalized for chest pain and dizziness. She was brought to the emergency department by Emergency Medical Services (EMS) for evaluation of hypertension, palpitations, dizziness and chest pain for one week. The patient's
past medical history included hypertension and depression. 
The patient's triage blood pressure was elevated to 178/118 and then vitals listed were stable: blood pressure 136/82, pulse 74, respiratory rate 18 and oxygen saturation 100%. The clinical 
impression was hypertensive emergency versus urgency. There were no acute electrocardiogram (EKG) changes or focal neurologic deficits. Chest film and head computed tomography (CT) scan were negative. Troponin panel was normal. Initial potassium was 7.9 and a hemolyzed specimen was noted; repeat was 3.2. Treatment included intravenous fluids and potassium. This is an appeal of the denied claim for the acute inpatient hospital stay.

The proposed acute inpatient stay was not medically necessary.

Based on review of the records and the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not 
meet the intensity of service for inpatient hospital stay. Criteria for inpatient hospitalization are not met, including chest pain with hemodynamic instability, respiratory distress, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism, hypertensive emergency with evidence of acute and progressing target organ disease, such as, hypertensive encephalopathy / altered mental status or cerebral infarction or intracranial hemorrhage or myocardial ischemia or infarction or heart failure with pulmonary 
edema, aortic dissection, increased creatinine (new) with reduction of more than 50% in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, other significant finding secondary to hypertension, adrenergic or sympathomimetic crisis, such as severe hypertension due to pheochromocytoma crisis; cocaine, phencyclidine, or amphetamine intoxication or clonidine withdrawal, severe hypertension (systolic blood pressure [SBP] greater than 180 millimeters of mercury [mmHg] or diastolic blood pressure [DBP] greater than 110 millimeters of mercury [mmHg] that cannot be 
controlled (e.g., to systolic blood pressure less than 160 millimeters of mercury and diastolic blood pressure less than 100 millimeters of mercury in adults) by emergency department or 
observation care treatment. Therefore, admission was not medically necessary, based on the submitted information and 
current published guidelines. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, 
including management of hypertensive urgency like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the 
current published medical literature, the proposed acute inpatient stay was not medically necessary.