Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm Labor 
Treatment: Inpatient hospital admission 

The insurer is denied coverage for inpatient hospital admission. The denial is upheld. 

This is a female patient who is at 34 weeks gestation who presented to the hospital with complaints of intermittent contractions, back pain, and copious amounts of mucus discharge. The examination revealed a cervix that was 3 cm dilated, 70% effaced at -2 station. The patient had occasional uterine contractions. Betamethasone, Tylenol, Ampicillin, Pepcid and intravenous (IV) fluids were ordered. The patient was admitted to rule out preterm labor. An obstetrical ultrasound revealed a single live intrauterine gestation cephalic presentation with an amniotic fluid index (AFI) of 11.1 cm and estimated fetal weight 2275 grams; no uterine contractions were noted. Vaginal exam revealed the patient was 1-2 cm dilated, 25% effaced, -3 station with intact membranes. The patient complained of back pain, but the progress note states she was not in labor. A 2nd dose of Betamethasone was ordered. A pelvic exam prior to discharge revealed she was 1-2 cm dilated, 30% effaced, posterior and high, and membranes were intact. She was discharged with preterm labor precautions. 

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. During this admission, there was no documentation of any cervical changes. So the patient was not in preterm labor. 

Please note that neither the patient nor the fetus were in any jeopardy. There was no bleeding, and vital signs were stable. Fetal heart rate was reassuring. There was no evidence of ruptured membranes. 

The management that this patient received during her admission could have been easily done in a less acute setting: Once the provider ascertained that there was no evidence of preterm labor, (no change in cervical status after few hours of observation) the patient could have been sent home after being hydrated. 

According to MCG admission is indicated for one or more of the following: 1) Condition requiring premature delivery 2) Fetal distress or demise 3) Preterm prelabor rupture of membranes 4) Significant maternal disease 5) Vaginal bleeding 6) Complications of tocolytic treatment 7) Continued fetal monitoring that require inpatient care 8) Tocolytic therapy needed that requires inpatient care 9) Inability to stop preterm labor. 

Observation care is appropriate for patients with one or more of the following: 1) Condition requiring premature delivery suspected 2) Preterm premature rupture of membranes suspected 3) Suspected maternal infection 4) Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed) 5) Fetal distress suspected 6) Suspected placenta previa, vasa previa or placenta accrete. 

Based on the above, since this patient was not in labor and was stable, admission to the
hospital was not medically necessary. This is in accordance with standard of care and Milliman guidelines (MCG). 

The health plan acted reasonably with sound medical judgment in the best interest of the
patient. 

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.