Diagnosis: Left Ringing Ear and Shortness of Breath (when lying down)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She had a pregnancy and delivery complicated by chorioamnionitis and gestational hypertension. She was admitted post op day 3 with a complaint of tinnitus.

The patient was found to have multiple severe range blood pressures establishing the diagnosis of severe postpartum preeclampsia. She was admitted and given magnesium sulfate and nifedipine. Her condition improved and she was discharged on maintenance nifedipine.

The health plan's reason for the denial was that the patient did not meet admission criteria for hypertension and that she would have required documentation of end organ damage per InterQual criteria for adult hypertension, and that the care could be given without admission to the hospital. The reason for appeal was that the patient met criteria per MCG (Milliman Care Guidelines) ORG M-285 Hypertensive Disorders of Pregnancy for preeclampsia with severe features including severe hypertension greater than 160/110 and cerebral symptoms and therefore the admission was medically necessary.

Yes, the inpatient admission was medically necessary.

Admission criteria for hypertension during pregnancy and puerperium are different than those for adults who are not pregnant or postpartum, due to the possibility of the hypertension being due to preeclampsia and particularly preeclampsia with severe features. This patient met clinical criteria for preeclampsia with severe features based on the severity of the hypertension, exceeding 160 systolic, as well as the new onset of cerebral symptoms (tinnitus has been reported in conjunction with preeclampsia and in one study was present in 7% of cases). Untreated severe postpartum preeclampsia can lead to intracranial hemorrhage, seizures, renal failure, pulmonary edema, hepatic injury, disseminated intravascular coagulation, hemorrhage, PRES (posterior reversible encephalopathy syndrome) syndrome with cortical blindness, and death. For these reasons the American College of Obstetricians and Gynecologists recommends admission and treatment with intravenous magnesium sulfate seizure prophylaxis as well as anti-hypertensives, as was done in this case. Therefore, the admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The health plan had declined coverage for the inpatient admission level of care, which was medically necessary.