Diagnosis: Malignant hypertension and monitoring of chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is the case of an adult female that presented to the hospital with headache, chest pain and poorly controlled hypertension (HTN). She was sent by ambulance after her blood pressure (BP) reading at an urgent care center was 230 systolic. Past medical history was significant for surgically corrected Scimitar syndrome, HTN with recent hospital admission for hypertensive crisis and non-obstructive coronary artery disease. Previous attempts to control HTN with amlodipine and angiotensin-converting enzyme (ACE) inhibitors were not successful. Upon arrival to the Emergency Department (ED), BP was 181/114 and pulse was 61 beats per minute. No abnormal findings were noted on physical examination. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with atrial premature complexes (APCs) and ST-T (intervals on ECG) wave abnormalities in the inferior leads. Serum level of brain natriuretic peptide (BNP) was elevated (225 pg/ml [picograms per milliliter]) and D-dimer (one of the protein fragments produced when a blood clot gets dissolved in the body) was elevated. A computed tomography (CT) angiogram revealed no evidence of pulmonary embolism. Echocardiogram revealed concentric left ventricular hypertrophy and a preserved left ventricular ejection fraction (LVEF). The patient was admitted to the hospital and treated with increasing doses of carvedilol and chlorthalidone. She was discharged after BP was adequately controlled.

This patient presented with hypertensive emergency, headache, and chest pain. She had a history of surgically corrected congenital heart disease. BNP levels were elevated, and ECG revealed T (interval on ECG) wave abnormalities. In addition, previous attempts to control BP with multiple agents were not successful. Hypertensive emergency is defined as BP > (greater than) 180/120 with target organ damage. (1)

In this patient, ECG revealed inferior wall ST-T wave changes and BNP was elevated, consistent with left ventricular wall stress and target organ damage. Given this patient's previous history, admission to the hospital for aggressive blood pressure management was necessary. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (2) Given this patient's failure to respond to outpatient medical therapy, admission to the hospital for aggressive blood pressure management was necessary.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The acute inpatient admission was medically necessary.

The insurer's denial of coverage for inpatient admission is overturned. Medical necessity is substantiated.