Diagnosis: Hypertensive Crisis

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.

This patient presented to the Emergency Department (ED) with complaints of lightheadedness, blurred vision, and weakness. Upon arrival to the ED the patient's blood pressure was 239/107. Hypertensive emergency is defined as BP>180/120 with target organ damage. (1) In this patient, blurry vision and lightheadedness were concerning for central nervous system (CNS) target organ damage. The patient had a computed tomography (CT) scan of the head that was negative for a transient ischemic attack (TIA) and an acute stroke. Based on the patient's initial clinical presentation, admission to the hospital was medically necessary for aggressive blood pressure management and control. She had an electrocardiogram (EKG) that revealed sinus rhythm with possible anterior wall myocardial infarction. Cardiac enzymes were drawn with negative results. The patient was discharged with instructions to follow up with an outpatient cardiologist.

American Heart Association guidelines recommend admission to the Intensive Care Unit (ICU) for management of hypertensive emergencies.(1) Following initial response to antihypertensive therapy, additional monitoring and treatment was necessary to achieve acceptable blood pressure control. Thus, inpatient hospital admission was medically necessary for this patient's case.

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

The carrier's denial of coverage for the inpatient hospital services is reversed. The medical necessity is substantiated.