Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical insufficiency during pregnancy. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a pregnant female patient who was sent to the Emergency Department (ED) from the obstetrics clinic for evaluation and management of cervical incompetency due to a short cervix. The patient reported normal fetal movements, and denied vaginal bleeding, leaking of fluids, headache, blurred vision or abdominal pain. The patient's fetal heart rate was reassuring.  The patient received intravenous (IV) fluids, IV magnesium, IV betamethasone, and IV clindamycin. The patient was medically cleared for discharge home with outpatient management with instructions to follow up with the obstetrics clinic.

According to Milliman Care Guidelines (MCG), admission is indicated for one or more of the following: Condition requiring premature delivery; Fetal distress or demise; Preterm prelabor rupture of membranes; Significant maternal disease; Vaginal bleeding; Complications of tocolytic treatment; Continued fetal monitoring that require inpatient care; Tocolytic therapy needed that requires inpatient care; Inability to stop preterm labor.

Observation care is appropriate for patients with one or more of the following: Condition requiring premature delivery suspected; Preterm premature rupture of membranes suspected; Suspected maternal infection; Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed); Fetal distress suspected; Suspected placenta previa, vasa previa or placenta accrete.

As per literature review, preterm labor is an indication for admission and tocolysis.  Preterm labor is defined as uterine contractions with cervical changes. However, in this case, the patient was not in preterm labor. During this patient's admission, there was no documentation of any cervical changes that were consistent with preterm labor. Ideally, this patient would have been observed in labor and delivery, received IV fluids and then reevaluated few hours later. If upon reevaluation, no cervical changes occurred then she would be sent home. If cervical changes did occur then she would be admitted for tocolysis and further management.

Based on the review of the medical record, there were not clinical findings indicative of jeopardy to either the patient or the fetus. There was no vaginal bleeding, and both the patient's and the fetal vital signs were stable. Fetal heart rate was reassuring. There was no evidence of ruptured membranes. The management that this patient received during her admission could have been easily done in a less acute setting. Once the provider ascertained that there was no evidence of preterm labor (i.e., no change in cervical status after few hours of observation), the patient could have been sent home after being hydrated. 

The inpatient hospital admission is not considered medically necessary for this patient.  This is in accordance with standard of care and the Milliman guidelines.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.