Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intrauterine Growth Restriction

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a female at 26 weeks and 5 days of gestation with a history of uterine fibroids. She presented to the hospital from another facility with complaints of vaginal bleeding, a short cervix, and abdominal pain. The patient was admitted to the Obstetrics unit. She was already being treated with vaginal progesterone for a short cervix and this was continued in the hospital. Labs were within normal limits.
 
An ultrasound revealed intrauterine growth restriction with an estimated fetal weight in the 8th percentile. There was no evidence of placental abruption. Daily non-stress tests were reactive and there was no evidence of preterm labor. Ibuprofen was given for pain related to fibroids and Imodium was given for diarrhea. The patient was discharged after a period of medical stability. 

According to Milliman Care Guidelines admission is indicated for one or more of the following:

-	Condition requiring premature delivery
-	Fetal distress or demise
-	Preterm prelabor rupture of membranes
-	Significant maternal disease
-	Vaginal bleeding
-	Complications of tocolytic treatment
-	Continued fetal monitoring that require inpatient care
-	Tocolytic therapy needed that requires inpatient care
-	Inability to stop preterm labor.

Observation care is appropriate for patients with one or more of the following:

-	Condition requiring premature delivery suspected
-	Preterm premature rupture of membranes suspected
-	Suspected maternal infection
-	Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed)
-	Fetal distress suspected. 
-	Suspected placenta previa, vasa previa or placenta accreta

This patient had the following diagnoses:

-	Uterine fibroids causing pain and was treated with Ibuprofen
-	Chronic diarrhea that was evaluated with prior Gastroenterology specialists. There was no evidence of electrolyte anomaly.
-	intrauterine growth restriction 
-	Short cervix previously diagnosed and managed with vaginal progesterone.

It is unclear why this patient was admitted to the hospital as none of the above diagnoses require hospital admission. 

The short cervix was being managed with vaginal progesterone and this was continued in the hospital. Vaginal progesterone does not require a hospital admission. 

Evaluation and follow-up for intrauterine growth restriction does not require a hospital admission. For patients with intrauterine growth restriction, serial ultrasound evaluation of fetal growth, fetal behavior (biophysical profile or non-stress test), and impedance to blood flow in fetal vessels (Doppler velocimetry) represent the key elements of fetal assessment and guide pregnancy management decisions. The purpose is to identify those fetuses that are at highest risk of in utero demise and neonatal morbidity and thus may benefit from delivery. Admission for fetal monitoring is not medically necessary.  The patient could be evaluated daily as an outpatient with non-stress tests and biophysical profile. 
 
Ibuprofen to manage pain caused by fibroids does not require hospital admission.

The patient's chronic diarrhea was being managed prior to admission and it is unclear what was done during the hospital admission.

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.

Based on the above, admission to the hospital was not medically necessary. This is in accordance with standard of care and Milliman guidelines.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld.  Medical necessity is not substantiated.