Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a gravida (G) 3 para (P) 1011 female who presented at 28 4/7 weeks gestation with complaint of vaginal bleeding for one day. She was aware that she had a prior ultrasound that had demonstrated a placenta previa complicating the current pregnancy. This had been noted on ultrasound. This was her first episode of vaginal bleeding/spotting and denied any contractions or abdominal pain. She had no contractions at presentation. The patient reported no vaginal leakage of fluid. She reported the episode to be painless, dark brown and odorless. She had no pain at presentation. She had no abdominal pain. The remainder of the review of systems was negative. She had a prior history of cesarean delivery at 38 weeks gestation with a birth weight of 2500 grams. She delivered by cesarean early due to premature rupture of membranes (PROM) in that pregnancy. She also had a prior 8 week miscarriage requiring dilation and curettage (D&C). There was no history of preeclampsia, gestational diabetes, or gestational hypertension. She reported no significant medical history and only had a prior cesarean and D&C for her surgical history. She was a non-smoker. She had no allergies.

The patient had normal blood pressure 112/60 with a heart rate of 93. Her respiratory rate was 16 and she was afebrile at 98.2 Fahrenheit (F). Fetal heart rate monitoring was reassuring at with a baseline of 155 beats per minute (bpm) and moderate variability. There were absent accelerations and absent decelerations for category 1 and reassuring testing. There were no contractions noted on monitoring. A speculum exam was completed and noted brown discharge and intact membranes. The clinical estimated fetal weight was 900 grams (g). The bleeding was brown there were no pads per hour used. An ultrasound was performed and noted a posterior placenta previa and positive fetal heart rate. The cervical length was normal at 3.5 centimeter (cm). The patient was noted to have her first antepartum vaginal bleeding and the presence of a posterior placenta previa with no active bleeding and old brown blood seen in the vaginal vault. There were no contractions and reassuring fetal testing. The patient was admitted for 24-hour observation and a plan was made to hold on steroids once vaginal bleeding were to get worse. She was started on intravenous (IV) fluids and had baseline labs with a complete blood count (CBC) and basic metabolic panel. Pad counts were also planned. There was no Heparin planned at that time.

The patient went on to get her first dose of betamethasone on the day of admission. A bedside ultrasound was performed which showed a vertex presentation with a biophysical profile of 8 of 8 and an amniotic fluid index of 10.5 cm. The Doppler was 3.1 and normal for gestational age. The cervix was closed. The fetal heart rate remained reassuring and category 1. There were no contractions noted on monitoring or by examination. The patient also completed magnesium sulfate for neuroprotection.  The patient had complaints of nausea and vomiting and had 4 episodes of vomiting on magnesium. She reported a mild headache but denied any change in vision. She reported feeling tired. She still had intermittent scant, brown vaginal discharge. The patient received 1 dose of Zofran 4 milligrams (mg) IV push at 8 PM when she first vomited, and this improved her symptoms temporarily. Her magnesium level was 5.2 at that time. Her creatinine was normal at 0.4. A 24-hour urine was also being collected at that time and she had adequate urine output overnight. The patient's examination remained normal. She was reduced to 1 g/h magnesium ongoing. The patient remained reassuring. The patient's coagulation studies remained normal. She had normal hemoglobin of 10.5 and hematocrit 31.7. The patient's second dose of steroids was given. The patient had a normal quad screen reported in this pregnancy. The patient continued to be followed at that time.

Laboratory studies were also completed during this hospitalization was noted the patient's blood type to be A+ with a negative antibody screen. Her hemoglobin was 11.3 with hematocrit 33.7 and platelet count 36. The patient had a normal recent metabolic panel. Coagulation studies were also normal to include a normal prothrombin time (PT), international normalized ratio (INR) and partial thromboplastin time (PTT). The patient remained stable by hemogram during the hospitalization without any significant change. She had normal liver function testing. Uric acid and lactate dehydrogenase (LDH) were both normal. The patient had normal thyroid stimulating hormone (TSH) and free T4 performed during hospitalization. Fibrinogen level was normal at 573. Coagulation studies also remained normal during that day of hospitalization. The patient's hemogram remained stable with hemoglobin of 10.7 and hematocrit 32.1 with platelets of 319. Basic metabolic panel also was stable at that time. Urinalysis was negative for protein. The patient's human immunodeficiency virus (HIV) was nonreactive. Ultrasound was performed on December 2 which noted an amniotic fluid index of 12.51 cm that was normal with a biophysical score of 8 of 8. The umbilical artery Doppler was normal at 2.4. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld, in whole.

The inpatient stay was not medically necessary for this patient who was admitted with threatened preterm labor and reassuring fetal status that responded to magnesium within 24 hours. Based upon a review of the medical records, the recommendations of the American College of Obstetrics and Gynecology (ACOG) and the Milliman Care Guidelines (MCG) Guideline entitled "Preterm Labor, Threatened, there would have been no medical necessity for acute inpatient level of care admission.
In this case, the patient was noted to have a singleton gestation at 28 4/7 weeks gestation with threatened preterm labor. There was a cervical exam on admission to document the cervix as closed and long by the physician on speculum exam and the transvaginal cervical length was also closed and long. Old blood was noted in the vaginal vault with no ongoing or active bleeding. The complete blood count was normal. However, given preterm bleeding and known placenta previa, a plan was made for ultrasound, magnesium for neuroprotection and steroids. The ultrasound and fetal monitoring were reported as normal and reassuring with a singleton gestation with normal fluid. The patient completed a 24 hour window of magnesium sulfate without complications. There was completion of two doses of betamethasone for fetal lung maturity. The patient did not require tocolysis as there were no contractions. In this case, the care rendered would have been appropriate at a lower level of care status.