Diagnosis: Hypertension.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.

The denial is overturned.

Asked to review the case of a woman with a history of hypertension that presented to the hospital complaining of cough, shortness of breath, and sore throat. Vital signs on presentation were BP (blood pressure) 188/108 mmHg (millimeters of mercury) and Pulse 99 bpm (beats per minute). Physical examination was unremarkable. 12 lead electrocardiogram (ECG) revealed normal sinus rhythm with left ventricular hypertrophy and associated repolarization abnormalities. QTc (interval on an ECG) was prolonged at 477 milliseconds. Serum blood testing revealed hypokalemia (2.9mEQ (milliequivalents/L (liter)) and abnormal high sensitivity troponin level (30ng (nanograms)/L). The patient was admitted to the hospital for observation and treatment. Potassium was repleted and BP was controlled with oral medications. Echocardiogram revealed a left ventricular ejection fraction of 75% with diastolic dysfunction and mild to moderate aortic regurgitation. Perfusion testing revealed no evidence of ischemia. Following treatment, QTc (interval on ECG) normalized, blood pressure was well controlled, and the patient was discharged with follow up.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) In this patient, troponin was elevated consistent with myocardial stress and target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Given this patients symptoms and elevated risk of coronary artery disease admission to the hospital for aggressive blood pressure management and diagnostic evaluation was necessary. Utilizing the HEART (history, age, risk factors, troponin) risk score this patient would have an intermediate risk of for major adverse cardiac events or death due to any cause. (Reference 3). In addition, the patient was noted to be hypokalemic with a prolonged QT interval on electrocardiogram and required electrolyte repletion and monitoring on cardiac telemetry. This patient's presentation and overall risk of future cardiac events were sufficient to warrant inpatient hospital admission. It was medically necessary to treat this patient at the inpatient level of care.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for hospital admission is overturned. Medical Necessity is substantiated.