Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Early Labor. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient is a (G) 7 para (P) 3033 who presented at 20 4/7 weeks gestation with a short cervix in a diamniotic/dichorionic twin gestation. The patient in this case was admitted for possible early labor. She was sent in for a short cervix. This was her 4th such visit for short cervix. She denied vaginal bleeding or contractions. She reported being wet on 4 occasions. She had no labor complaints and was admitted to the antepartum service for further management. 

The patient noted a prior history of a urinary tract infection twice in the past two months. She was treated for these. She had a short interval pregnancy. Her obstetrical (OB) history was noted for three term deliveries with her largest infant at 9 pounds (lbs) 13 ounces (oz). She had no history of postpartum hemorrhage or Neonatal Intensive-Care Unit (NICU) admission for her infants. She had two prior first trimester dilation and curettage (D&C) procedures. She also had a prior first trimester completed miscarriage. She had no fibroids and a history of herpes simplex virus (HSV). She denied a history of any other sexually transmitted infections. The review of systems was noted for constipation. It was otherwise negative. The patient had no prior medical history and no prior history of surgery. She was noted to be on prenatal vitamins and Valtrex. She had an allergy to Sulfa. She had a normal blood pressure of 127/62 and heart rate of 105. Respirations were 19 per minute. She was afebrile at 99.1 degrees Fahrenheit (F). An ultrasound was completed and noted intact membranes with normal amniotic fluid index (AFI) by deep vertical pocket in each twin. The cervix was 1 centimeter (cm) long. She had a normal exam and negative evaluation for passive range of motion (PROM). She had a closed cervix. The patient was consented for possible cerclage in the morning. She had an evaluation for sexually transmitted infections and urine culture. She was also pending a Group B streptococcus (GBS) swab. These labs were noted to be normal. The patient was counseled on options for cerclage versus expectant management and opted for expectant management. She initially desired cerclage but then opted for expectant management. She was discharged to home with outpatient follow up scheduled. She was swabbed for coronavirus disease (COVID) 19 and was negative. Vaginal progesterone was considered at that time. At issue is the medical necessity of an inpatient stay. 

Based upon a review of the medical records and the current standards of care applicable to a twin gestation with a short cervix, an acute inpatient stay was not medically necessary. 

In this case, the patient was preterm, previable at 20 4/7 weeks with a diamniotic/dichorionic twin gestation with an asymptomatic short cervix. She had no signs or symptoms of preterm labor. She was under consideration of a possible plan of placement of cerclage due to an incompetent cervix since she was noted to have a short cervix. The patient had a short cervix noted by transvaginal cervical ultrasound that measured 1 centimeter (cm) long. This was closed on digital exam. She was planned for rescue McDonald cerclage if desired after clearing her infection workup. However, the patient desired no intervention and expectant management with vaginal Prometrium and the cerclage was canceled. She had no other events or complications of care. 

The standard of care in management of a twin gestation with an incompetent cervix would not include a cerclage. The American College of Obstetricians and Gynecologists (ACOG) states the following: "Interventions, such as prophylactic cerclage, routine hospitalization and bed rest, prophylactic tocolytics, and prophylactic pessary, have not been proved to decrease neonatal morbidity or mortality and, therefore, should not be used in women with multifetal gestations." If preterm labor was detected, steroids would be administered at 24 weeks (not indicated in this case given previable state) and magnesium for neuroprotection would be considered for 12 hours for neuroprotection at 24 weeks gestation. This may be continued to achieve 48 hours of tocolysis to complete steroids at beyond 24 weeks. A woman with a singleton or twin gestation and no prior spontaneous preterm singleton birth should be offered progesterone supplementation starting at 16-24 weeks of gestation by vaginal insert (200 milligrams (mg) prometrium) to reduce the risk of recurrent spontaneous preterm birth (approximately [~] 50% reduction when short cervix noted). Cerclage is not indicated in this case given a twin gestation. Thus, in this case, the care could have been provided at a lower level of care.