Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) from home for the sudden onset of palpitations which woke him up from sleep. The patient reported that his heart was racing and he became anxious and called Emergency Medical Services (EMS). After EMS arrived, his blood pressure (BP) was in the 200 range. The patient had associated blurry vision and a headache. The patient's BP usually runs in the 150s-170s.
His medications recently were adjusted, losartan was changed to Losartan 100-12.5 one week prior. The patient was told he had a kidney problem. His past medical history was significant for hypertension (HTN), chronic kidney disease (CKD).
In the ED his BP was 168/98, heart rate (HR) 68, temperature was normal, and oxygen saturation (O2 sat) 100 % (percent).
His physical examination was unremarkable. His creatinine was 1.5. An electrocardiogram (ECG) revealed normal sinus rhythm, left ventricular hypertrophy (LVH) and T wave likely due LVH. A chest x-ray (CXR) was normal. Computed tomography angiography (CTA) of the chest was negative for pulmonary emboli. The patient was given intravenous (IV) 10 milligrams Labetalol in the ED.
The patient was admitted to the hospital, to a telemetry bed with a diagnosis of hypertensive emergency. The plan was to resume home medications, aspirin, discontinue intravenous fluids (IVF), and order an echocardiogram (ECHO).
The patient was started on oral Labetalol. Losartan hydrochlorothiazide (HCTZ) was held. The next day, his BP was 165/93. The patient was complaining of palpitations. Losartan HCTZ was resumed. The plan was to keep the patient for another 24 hours and arrange cardiology follow up, Ziopatch and stress test as an outpatient.
The patient remained stable. Amlodipine was added. His echocardiogram was done and revealed normal left ventricular (LV) function. The left ventricular ejection fraction (LVEF) was 65-70%. Right ventricular (RV) function was normal. The left atrium was mildly dilated. The mitral and aortic valve were structurally normal.
The patient's condition was stable. He felt better. His creatinine went down to 1.2 and then was in the range of 1.2-1.4.
The patient was discharged home. Losartan was discontinued (causing dizziness) and he was treated with amlodipine and HCTZ.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient.

The patient presented with palpitations and elevated blood pressure. His condition was stable, he did not have any evidence of acute end organ damage from high BP: there was no evidence of acute coronary syndrome, pulmonary edema or encephalopathy. His creatinine was elevated, but only slightly.
The patient was treated mainly with oral medications. His echocardiogram did not reveal significant abnormalities. The patient's condition and his management did not meet inpatient admission criteria. A lower level of care would have been more appropriate.
 Per the first reference: "The overall therapeutic goal in patients presenting with hypertensive emergencies is a controlled BP reduction to safer levels to prevent or limit further hypertensive damage while avoiding hypotension and related complications. There is a lack of randomized controlled trial data to provide clear cut guidance on BP targets and times within which these should be achieved. Most recommendations are based on expert consensus. The type of acute hypertension-mediated organ damage (HMOD) is the main determinant of the preferred treatment choice. The timeline and magnitude of BP reduction is strongly dependent on the clinical context. For example, acute pulmonary edema and aortic dissection require rapid BP reduction, whereas BP levels not exceeding 220/120 mmHg(millimeters of mercury) are generally tolerated in acute ischemic stroke for certain periods. Table 12 provides a general overview of timelines and BP targets as well as preferred antihypertensive drug choices with most common clinical presentations. Availability of drugs and local experience with individual drugs are likely to influence the choice of drugs. Labetalol and nicardipine are generally safe to use in all hypertensive emergencies and should be available wherever hypertensive emergencies are being managed. Nitroglycerin and nitroprusside are specifically useful in hypertensive emergencies including the heart and the aorta".