Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy (with blurred vision, high blood pressure)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a pregnant female. She presented to the facility complaining of elevated blood pressure and blurry vision for 2 days at 31 weeks 3 days gestation. She had a history of chronic hypertension and was maintained on 300 mg (milligrams) labetalol bid (twice daily).

In triage the patient's blood pressures were noted to be 139-168/81-102 with two documented severe range pressures. Previously blood pressures were in the 120/80 range at home. Labs were notable for new onset of borderline thrombocytopenia of 149. Due to concern for development of superimposed preeclampsia with severe features, the patient was admitted and given intravenous magnesium sulfate for seizure prophylaxis. Her labetalol was increased to 300 mg (milligrams) tid (thrice).

With continued observation and increase in the antihypertensive the blood pressure elevation resolved and the patient was discharged home.

The health plan contends that the admission was not medically necessary based on the absence of unstable vital signs, severely high blood pressures, thrombocytopenia, abnormal liver functions, worsening renal function, hemolysis, pulmonary edema, end organ damage, or seizures and cites MCG (Milliman Care Guidelines) 25th edition "Hypertensive disorders of pregnancy". The facility contends that the admission was medically necessary due to new onset of visual changes and elevated blood pressure.

Yes, the Inpatient admission was medically necessary.
The patient was at very high risk for development of superimposed preeclampsia with severe features due to her history of chronic hypertension. At the time of her presentation she exhibited blood pressures in the severe preeclampsia range as well as visual changes and thrombocytopenia and therefore met criteria for the diagnosis of preeclampsia with severe features. This requires inpatient care for the administration of intravenous magnesium sulfate for seizure prophylaxis as well as careful monitoring to determine the clinical course as worsening of the preeclampsia would mandate preterm delivery.

In this patient's case, it was determined that it was more likely that the cause of the abnormalities was a need for a higher dose of anti-hypertensives. However, at the time of presentation it was necessary to admit and give the intravenous magnesium and perform the monitoring to ensure patient safety and to resolve the diagnostic issues, because severe preeclampsia could not be excluded at that time.

Preeclampsia with severe features is a life threatening condition for both mother and fetus. From the fetal perspective, it can lead to intrauterine hypoxia and hypoxic injury, fetal growth restriction, and fetal death in utero. From the maternal perspective it can lead to seizures, intracranial hemorrhage, renal failure, liver injury, pulmonary edema, abruptio placentae, hemolytic anemia, disseminated intravascular coagulopathy, hemorrhage, and death. Due to the severity of these complications, the standard of care requires that if there is any question of preeclampsia with severe features that the patient be admitted and administered intravenous magnesium sulfate and monitored until the diagnostic issue can be resolved.

Therefore, given the above, the Inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The health plan declined coverage for the inpatient level of care, which, as noted above, was medically necessary.