Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Premature Labor, Vaginal Bleeding
Treatment: Continued Inpatient Hospital Admission
The insurer denied Continued Inpatient Hospital Admission.
The denial is partially approved.

The patient is an adult G1 (Gravida 1-first pregnancy) female. She presented to the hospital at 31 weeks, 5 days' gestation complaining of rupture of membranes with clear amniotic fluid and uterine contractions. On initial evaluation, a cervical exam was done which was 6 centimeters dilation. Based on this evaluation, the presumptive diagnosis of active preterm labor with premature rupture of membranes was made, and the patient was admitted to the hospital and given magnesium fetal neuroprotection, antenatal steroids for lung maturation, antibiotics per Mercer protocol for preterm premature ruptured membranes, and an epidural catheter was placed for labor analgesia. Subsequent to placement of the epidural, a cervical exam was done, which was 1 centimeter, which ruled out active labor, barring progression of the cervical dilation on subsequent exams. An ultrasound was performed that revealed normal amniotic fluid volume and so the diagnosis of ruptured membranes was felt to be incorrect. Vaginal bleeding was then observed, which raised a concern for placental abruption. On hospital day (number) #2, exam revealed only spots of blood were noted, and the cervix was unchanged. However, frequent uterine contractions were noted every three to five minutes and rated as 6/10 in intensity. There continued to be a concern for concealed abruption and so the patient was not discharged from the hospital and remained for another day of observation. On hospital day (number) #3, no active bleeding was noted, the contractions had resolved, and the patient denied leakage of fluid. The patient was observed overnight with no changes and was discharged home on hospital day (number) #4. The health plan had previously approved hospital days (number) #1 and #2 but was denying payment for days (number) #3 and #4 based on medical necessity no longer being present. The health plan contends that the extended admission was not medically necessary, because there was no evidence of acutely managed complications and cited MCG (Milliman Care Guidelines) criteria ORG M-287H. The patient contends that the hospital stay was medically necessary due to the possibility she could bleed out because of the placental abruption. No statement addressing the denial from the physician or facility was present in the material reviewed.

The Continued Inpatient Hospital Admission was medically necessary, in part. Specifically, the admission was medically necessary for hospital days (number) #1-3, but not for hospital day (number) #4.

There was a reasonable concern for prolongation of the hospital stay on day (number) #2 given that vaginal bleeding and frequent painful contractions were documented. Although there was no documented cervical change, advanced cervical dilation, or documented rupture of membranes, the presence of persistent frequent uterine contractions with vaginal bleeding could be a sign of concealed abruption, which may develop rapidly into a clinically significant abruption that might require emergent intervention. However, on hospital day (number) #3, the contractions and bleeding had resolved, the heart rate tracing was normal, and there was no evidence at that point of high risk for progress of a concealed abruption. Therefore, continuation of the hospitalization was medically necessary for hospital days (number) #1-3, but not subsequent to that time (hospital day #4).