202305-162436
2023
Fidelis Care New York
Medicaid
Cardiac/ Circulatory Problems
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Nausea and vomiting
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
This is an adult female who presented to the hospital complaining of nausea and vomiting for one week. On arrival she was noted to be hypertensive, and the patient reported that she was unable to take her antihypertensive medications. Past medical history was significant for hypertension, diabetes mellitus, gastroparesis, peripheral and vascular disease status post metatarsal amputation. Blood Pressure on arrival was 213/136 millimeters of mercury (mmHg) and pulse was 94 beats per minute. Physical examination was unremarkable. 12 lead electrocardiogram revealed normal sinus rhythm without ST or T wave abnormalities. Serum blood testing demonstrated no elevation in troponin (0.079ng/ml) and a creatinine of 1.4 mg/dl. The patient was treated with nifedipine and labetalol and admitted to the hospital for further treatment. Blood Pressure was immediately controlled, and the patient was released on oral medications the following day.
Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) In this patient, target organ damage was not present. 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) This patient was unable to take medications due to nausea and vomiting. Following treatment for nausea, the Blood Pressure was immediately controlled with re-initiation of oral antihypertensive medications. In conclusion acute inpatient admission was not medically necessary.
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.