Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested continued care with a perinatologist for treatment of her pregnancy.  Findings:  The physician reviewer found that fetal growth monitoring can be performed through the process of monitoring the patients weight gain, serial fundal height progression and ultrasonographic calculation of estimated gestational age, estimated fetal weight, and amniotic fluid index. The process of monitoring patient weight gain and watching serial fundal heights is the mainstay in the obstetrical office, and was already occurring in this patients case. Most obstetrical offices have the ability, either by utilizing a sonogram tech, or by using a physician trained in performing obstetrical ultrasounds, to perform in-office sonograms or have sonogram services available outside of the physicians office. Basic ultrasonography is utilized to measure femur length, abdominal and head circumference, and BP diameter which are then used to calculate an estimated gestational age and fetal weight. An AFI can just as easily be obtained. This information, when obtained with serial measurements, can then be used to monitor the fetal growth. Typically, if the fetus is found to have intrauterine growth restriction or oligohydramnios, then many obstetricians will utilize a maternal fetal specialist (e.g., perinatologists) to help monitor the progression of growth, typically with similar processes of estimating gestational age and serial fetal weights, but also by utilizing uterine artery, cerebral artery and umbilical Doppler to assess placental function. This can help aid in determining if early delivery is indicated. Preterm labor monitoring is typically individualized to the particular patient and the particular pregnancy. Typical risk factors for preterm delivery include: previous history of preterm labor and delivery, multiple gestation, uterine anomalies and fibroids, polyhydramnios, advanced maternal age (AMA), chronic hypertension, chronic medical disease of the mother, maternal infections, and disorders of the cervix. It is true that this particular patient has an increased risk for preterm delivery, as she had known risk factors, specifically, polyhydramnios and AMA. Over the years, several approaches have been utilized to monitor patients at increased risk for preterm delivery, including prophylactic therapy versus close monitoring by attempted predicative measures with or without prophylactic therapy. Attempted predicative monitoring for preterm labor has included the use of serial obstetrical ultrasound to measure cervical lengths and funneling, and cervical swabs for the Fetal Fibronectin (FFN) protein. These services including the use of FFN can be (and typically are) performed by the generalist obstetrician. In the notes from the perinatologist, there is no documentation of follow-up that is specific to perinatology care. What has been recommended are treatment protocols familiar and typically performed by the generalist obstetrician. These patients can and sometimes will have perinatal consultation for these management options, but typically are cared for by the generalist. This fetus does have an echogenic focus in the heart, which was evaluated by CVS (normal genetics) for genetic evaluation of Trisomy, and maternal serum viral TORCH titers were normal. All told, there was no clinical indication for continued care with a perinatologist in this patients case.Based upon the information set forth above, there is no evidence that services with a perinatologist were medically necessary in the past or are medically necessary going forward.