Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive emergency with new onset heart failure
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The adult patient  presented to the hospital with a history of asthma, diabetes, obstructive sleep apnea, obesity, and hypertension. The patient complained of wheezing and dysuria, although the patient later denied dysuria.  Vital signs of the patient noted blood pressure of 194/121, heart rate of 101, respiratory rate of 18, and temperature of 98.4 F.  The patient's blood sugar was 683 which improved to 261 with lispro insulin. There was a plan for primary care provider referral to address glycemic control and nebulizer solution to the patient's pharmacy. The patient had been deemed stable for discharge, however upon further review of laboratory testing, troponin was found to be elevated. There was a plan to return the patient to the Emergency Department (ED) for second troponin/creatinine kinase, and electrocardiogram (EKG). The second troponin was positive, unchanged, and there was hyperglycemia. The patient reported for the last month or so that every time that they walked a block, they would get short of breath and have to stop to rest. Vital signs noted blood pressure 161/97, heart rate of 103, respiratory rate of 22, temperature 97.4 F, and oxygen saturation of 94%. There was a plan for telemetry admission with serial EKG's. Laboratory results noted sodium of 133, chloride of 95, creatinine of 1.36, glucose of 639, albumin of 3.1, alkaline phosphatase of 142, troponin of 0.05, creatine kinase of 382, and brain natriuretic peptide (BNP) of 201. There were no ischemic changes on EKG. The patient had exertional shortness of breath which could be related to inadequately controlled asthma versus anginal equivalent. There was no evidence of acute coronary syndrome at the current time.  The findings were likely demand in the setting of hyperglycemia and hypertension. There was no further need to trend troponins.  EKG noted sinus tachycardia at 111, incomplete left bundle branch block, and left atrial enlargement. The patient was seen by Endocrinology.  Glucose was 715. The patient had changes to insulin regimen. Hemoglobin A1c was 12%. A stress test was completed which noted a large left ventricular with moderate to severe global systolic dysfunction. Myocardial perfusion testing noted that the patient had chest discomfort during testing. The EKG was without significant change from baseline abnormalities. The patient's blood pressure was elevated with diastolic greater than 100 during testing. Cardiac follow-up noted blood pressure ranged from 160-190/110-221. Work-up was consistent with nonischemic cardiomyopathy. 

Inpatient admission was indicated for patients presenting with hemodynamic instability as indicated by tachycardia that persist despite appropriate treatment. The patient had a glucose of 639, tachycardia, and elevated troponin. The patient had elevated blood pressure of 194/121. The patient was in hypertensive emergency with new onset heart failure.

Per the cited references, admission to the hospital is indicated for hypertensive emergency with systolic blood pressures greater than 180 or diastolic blood pressures greater than 120 with evidence of acute or worsening target organ damage as indicated by myocardial ischemia, infarction, heart failure, or renal failure. In this case, the patient presented to the hospital with complaints of wheezing. The patient was noted to be hypotensive and tachycardic with hyperglycemia. Troponin was elevated but stable. It was argued that the inpatient admission on was medically necessary as the patient was in hypertensive emergency with new onset heart failure. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is substantiated.