Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Postpartum preeclampsia
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

The patient, a gravida 2 para 2, was admitted to the hospital for postpartum preeclampsia. She was admitted 5 days after a routine vaginal delivery when she presented with systolic blood pressures as high as the 170's, along with a severe headache and other symptoms. She required antihypertensive medication and magnesium seizure prophylaxis. The patient also had profound bradycardia to the 40's and dyspnea from pulmonary edema. The blood pressures and other symptoms were controlled by hospital day 3, and the patient was discharged with outpatient follow-up. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. This patient presented with severely elevated blood pressures and a severe headache. She was unstable. She reported a headache with neurologic symptoms on the day of admission, which is the top predictor of an eclamptic seizure. She needed admission and intensive management. Magnesium was appropriately administered to prevent eclamptic seizure, a complication that can lead to death or disability. Currently, though pre-eclampsia is less common in the postpartum period, eclamptic seizures are much more common after delivery. The reason for that is that the use of magnesium and other anti-epileptics in the antepartum setting is aggressive, but there is less opportunity for treatment after the patient has left the hospital. This patient's providers were appropriately concerned about the possibility of seizure and took aggressive action to prevent that outcome. Though this patient was 5 days from delivery, an eclamptic seizure can occur at anytime in the first 6 weeks postpartum. This was a seriously ill patient, and inpatient care was medically necessary. The level of danger and the intensity of intervention in this case are compelling reasons why this patient required an inpatient care and could not receive care at a lower level.
Postpartum pre-eclampsia is a highly dangerous condition that even in the postpartum setting can lead to a seizure or cerebrovascular accident. Control of hypertension is essential, and difficult to establish outside the hospital without the benefit of monitoring. This patient required antihypertensive medication upon admission. Observation status refers to interventions that could be accomplished in an outpatient or emergency setting. Magnesium sulfate administration, essential in this case, does not fit that criteria. Intravenous magnesium is considered a high-risk medication, and requires intensive monitoring by nursing staff. Clinical evaluations at least every 30 minutes are standard to monitor for toxicity. The Food and Drug Administration (FDA) labeling for the drug magnesium sulfate is specific about intensive monitoring including tracking of urine output. Also significant in this case was pulmonary edema, a dangerous consequence of pre-eclampsia. She had dyspnea with documented oxygen saturations as low as 85% (percent). A computed tomography (CT) scan of her lungs confirmed pulmonary edema. She required multiple doses of Lasix over 3 days to resolve this and improve her respiratory status. Appropriately, a full cardiology work-up was initiated as well. She also had the unusual history of myelin oligodendrocyte glycoprotein associated disease after her first delivery, resulting in three weeks without sight. Her physicians had to be even more concerned with this in her background. This was a complex patient with multiple life-threatening issues. Hypertensive disease of pregnancy remains the third most common cause of maternal death. Recent highly publicized efforts at reducing maternal mortality have called for more aggressive action of patients presenting with pre-eclampsia. Treatment of postpartum pre-eclampsia requires rapidly changing medications and a high level of nursing intervention because a life-threatening seizure can occur anytime.
An inpatient stay was medically necessary for this patient.