Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological 
Treatment: Inpatient hospital admission 
The insurer denied inpatient emergency admission. 
The denial is upheld.

The patient is a gravida (G)5 para (P) 3013 female with a diagnosis of miscarriage (failed pregnancy) who presented at 13 weeks gestation after being sent to the emergency department by her obstetrician with complaints of worsening cramping and vaginal bleeding. The patient first presented to the emergency room the previous day with vaginal spotting and was diagnosed with a missed abortion at that time. She followed up with clinic and was scheduled for dilation and curettage (D&C) on the next Wednesday. The patient reported increasing bleeding on the day of presentation and began to soak pads but was unable to tell how many. This was associated with the passage of large clots, but she was unsure if she had passed the fetal tissue. She denied lightheadedness, dizziness, weakness, abdominal pain, or other complaints. Her bleeding had improved at presentation. She had no nausea or vomiting. She reported no fever, chills, shortness of breath, chest pain or leg pain.

The patient was counseled on options including conservative management and medical management with Cytotec as well as surgical management. She was reviewed on the risks and benefits of each option and decided to proceed with surgical management. A plan was made for dilation and curettage in the morning. There was no need for emergent D&C, as the patient was stable and bleeding had slowed. She was made nothing by mouth and intravenous (IV) fluids were started. The patient was given deep vein thrombosis (DVT) prophylaxis and a consent was signed. Doxycycline was ordered for the operating room, and she was added on for the operating room emergently. Ibuprofen was given for pain. The patient was taken to the operating room, where she underwent general intubation and dilation and curettage for a missed abortion at 12 weeks gestation. The patient underwent an uncomplicated dilation and curettage without difficulty and was noted to have an estimated blood loss of 100 milliliters (mL), including products of conception. Pathology was sent and confirmed products of conception in this case. The patient was taken to the recovery unit and was noted to have stable vital signs and normal blood pressures for a postpartum pregnant patient. The patient was discharged to home with follow-up in the outpatient setting. The subject under review is the medical necessity for inpatient emergency admission.

The health plan's determination is upheld.

The admission was not medically necessary at the acute inpatient level of care status for this patient, given the diagnosis of missed abortion pregnancy with stable vital signs and no evidence of coagulopathy or infection. The American College of Obstetrics and Gynecology (ACOG) recommend that the care for a missed abortion with dilation and curettage should be an ambulatory level of care and does not require acute inpatient medical care. In this case, the minimal invasive approach to surgery and normal recovery would be anticipated to result in observation level of care or discharge to home after surgery. In this case, the patient met the ability to have pain controlled with oral medications, tolerate regular diet, and ambulate. She had no limitations to understanding post operative instructions. Thus, she was eligible for a lower level of care and discharge to home. Based upon a review of the medical records and the procedures and course of care, there would be no medical necessity for acute inpatient level of care for a dilation and curettage for failed pregnancy; the patient could have been managed at a lower level of care status.