Diagnosis: Elevated blood pressure, chest pain, cough, body aches.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is upheld.

The patient is a female with hypertension and chronic kidney disease (previous creatinines 1.4-1.5), who presented to the hospital with chest pain, cough, congestion, body aches, fatigue, and sore throat after being noted to have a blood pressure of 220/110 at an outpatient clinic. On presentation the patient complained of left-sided chest pain. Labetalol was administered in the emergency department. Labs were notable for a creatinine of 1.6. The patient was alert and oriented. A renal ultrasound demonstrated no hydronephrosis. The electrocardiogram showed sinus rhythm without acute ischemic changes, and cardiac enzymes were negative. Computed tomography of the brain demonstrated no acute process. The blood pressure was 199/116 on admission. The patient was monitored on telemetry, cardiology consulted, and oral antihypertensive agents were provided. The blood pressure improved with adjustment of oral antihypertensive agents. The urine culture grew coagulase-negative staphylococcus, which was felt to represent a contaminant.

No, the inpatient admission was not medically necessary.

The patient's chest pain was not accompanied by evidence of acute coronary syndrome. Cardiac enzymes were negative, and the electrocardiogram showed no acute ischemic changes. Although the blood pressure was significantly elevated on presentation, there was no evidence of hypertensive emergency, as there were no end-organ manifestations of the elevated blood pressures, such as acute cerebrovascular accident, hypertensive encephalopathy, microangiopathic hemolytic anemia, acute heart failure, or syncope. The creatinine of 1.6 on presentation was only minimally greater than baseline creatinine of 1.4-1.5. The member did not have hyperkalemia, uremia, acidosis, or volume overload. In summary, acute inpatient admission was not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the member in making its determination.