202002-125801
2020
Healthfirst Inc.
Medicaid
Cardiac/ Circulatory Problems
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Headache; Dizziness
Issue under review: Inpatient admission
Determination:
The denial was upheld.
The patient is an adult female with diabetes, coronary artery disease, and hypertension. She presented to the hospital with increasing blood pressures on an outpatient basis.
The patient's blood pressure on presentation was 183/115, and the patient was without acute complaints. Laboratory indices were unremarkable, and the chest x-ray and computed tomography of the brain showed no acute process. Oral antihypertensive agents (nifedipine and valsartan) were provided, and serial blood pressure were monitored. The patient's blood pressure normalized.
The patient's elevated blood pressures on presentation were asymptomatic. There was no evidence of hypertensive emergency, as the patient did not have end organ damage, such as seizure activity, hypertensive encephalopathy, acute cerebrovascular accident, acute kidney injury, acute myocardial ischemia, or acute heart failure. No intravenous antihypertensive agents were provided. The blood pressure normalized with only oral antihypertensive agents. In addition, glycemic control was acceptable.
In summary, inpatient admission was not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.