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202001-125031

2020

Empire BlueCross BlueShield HealthPlus

Medicaid

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Cardiac/Circulatory Problems
Inpatient hospital

This is a case of a man with a history of hypertension diabetes and hyperlipidemia, presenting to the emergency room with complaints of left shoulder and arm pain, with radiation into the left hand. Symptoms have been present for at least a week, with associated intermittent headaches and blurred vision. The patient denied chest pain or shortness of breath. There was no associated nausea or vomiting. Vital signs on arrival included a temperature of 97.9 Fahrenheit, respirations of 26, and blood pressure of 204/127. The heart rate at this time is documented at 84 beats per minute (bpm). On exam, the patient is described as well-appearing well-nourished awake, and alert. The cardiac exam showed a regular rate and rhythm with normal heart sounds and no murmurs. The pulmonary exam was fairly unremarkable, and so was the rest of the exam.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This presentation of hypertensive urgency can be managed under at a lower level of care. The presentation does not satisfy clinical indications for admission to inpatient care. The patient has a diagnosis of hypertensive urgency or emergency, without evidence of target organ damage. There is no evidence of hypertensive encephalopathy or cerebral infarction. There is no evidence that the patient suffered from myocardial ischemia or infarct. There is no evidence of heart failure or aortic dissection. There is no evidence of seizure activity associated with hypertensive urgency. Within 24 hours, the addition of antihypertensive medications produced adequate control of blood pressures. This type of presentation is typically managed at a lower level of care for chest pain rule out protocol.

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