Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned in part.

This case involves a male who presented to the emergency department with reports of dizziness, headache, and nausea. Records noted the patient had a history of CABG (coronary artery bypass graft) and cardiac stents. Prior to his arrival at the emergency department, he took losartan 100 mg (milligrams) and 50 mg. He reported a blood pressure reading at home of 211/119. When he was initially assessed, his blood pressure readings were 220/118, 185/115, 197/118, and 220/101. A CT (computed tomography) of the head revealed a focal high-grade stenosis of the P2 (post-communicating) segment of the right posterior cerebral artery and stenosis of the proximal internal carotid artery secondary to calcification. Initial treatment in the emergency department included intravenous labetalol 20 mg, intravenous Reglan 10 mg, and meclizine 50 mg. His diagnoses at the time of the assessment were dizziness and hypertension. The patient was admitted to telemetry for a further work-up. The final adverse determination letter stated that there was no evidence of hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care. The services and interventions could have been performed in the observation setting. There were no positive tests or other findings after evaluation by the physicians that would have required an acute level of care. An appeal letter was submitted stating that the patient had persistent neurological symptoms and hypertension requiring inpatient care for neurological work-up, diagnostics, and treatment. 

The Milliman Care Guidelines state that when a patient presents with hypertension, the goal length of stay for treatment is 2 days. Clinical indications for admission to inpatient care include systolic blood pressure greater than 180 mmHg (millimeters of mercury) or diastolic blood pressure greater than 120 mmHg with evidence of acute or worsening target organ damage is indicated by 1 more the following to include hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, or other acute or worsening end organ damage due to severe hypertension. Alternatives to admission include gradual lowering of blood pressure and observation with close outpatient follow-up with continuing gradual lowering of blood pressure over ensuing 24 to 48 hours. The information provided for the review noted that the patient's initial blood pressure readings were showing systolic pressures over 180. He had associated symptoms of dizziness and nausea. The patient had a history of prior cardiac surgery to include CABG and cardiac stents. Given his presenting symptoms and findings during triage, inpatient care was considered appropriate. After that, it was reasonable for the patient to stepdown to a lower level of care given that his vital signs stabilized with treatment. His care could have been managed on an observational basis or outpatient basis. Therefore, the prior determination is partially overturned.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is modified. Medical Necessity is substantiated.