Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Hypertension

Treatment: the inpatient emergency admission

The insurer denied coverage for the inpatient emergency admission.

The denial is upheld.

The patient is a pregnant female with no significant past medical history. Her pregnancy had been complicated by elevated blood pressure. She had a diagnosis of chronic hypertension. The patient reported a history of "kidney problems". She presented to the hospital with elevated blood pressures. She was admitted to rule out preeclampsia (PEC). The patient was given two doses of betamethasone. Blood pressures continued to be within the mild range. A 24-hour urine protein was negative. A renal ultrasound (US) revealed right renal agenesis. Renal dopplers revealed right renal artery stenosis. Nephrology consulted over the case. They recommended laboratory studies. They also recommended outpatient follow up with renal, urology, and vascular postpartum. Vascular surgery recommended no acute management and obtaining repeat dopplers in 6 months. Maternal fetal medicine (MFM) recommended outpatient follow up. She was discharged.

According to the medical records, the patient was admitted for pregnancy induced hypertension evaluation, betamethasone administration, and monitoring of blood pressure. 

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after few weeks of gestation in a previously normotensive woman. 

Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 mm Hg (millimeters of mercury) or higher, or diastolic blood pressure of 110 or higher) should be diagnosed with preeclampsia with severe features. These severe ranges of blood pressure increase the risk of morbidity and mortality.

According to American College of Obstetrics and Gynecology (ACOG), ambulatory management at home is an option only for women with gestational hypertension or preeclampsia without severe features and requires frequent fetal and maternal evaluation. Hospitalization is appropriate for women with severe features. 

This patient did not have preeclampsia.

Note that betamethasone administration does not require hospital admission.

Please note that neither the patient nor the fetus were in any jeopardy. Fetal heart rate was reassuring. There was no evidence of ruptured membranes.  Milliman Care Guidelines (MCG) list the following clinical indications for admission:

-	Condition requiring premature delivery
-	Delivery
-	Fetal distress or demise
-	Preterm labor and positive fFN [Fetal fibronectin]
-	Significant maternal disease, infection or comorbidity as cause
-	Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete.
-	Continued fetal monitoring
-	Tocolytric therapy that requires inpatient care
-	Complications of tocolytic treatment

This patient did not have any of the above. She is known to have chronic hypertension. She could have been observed in labor and delivery. Once preeclampsia was ruled out, she could have been discharged to be followed up and tested as an outpatient. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient emergency admission is upheld. Medical Necessity is not substantiated.