Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth. 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a female, gravida (G) 1 para (P) 0 who presented by Emergency Medical Services (EMS) transport after a restrained motor vehicle accident. The patient was at 34-4/7 weeks gestation at the time of presentation. The patient had her seatbelt on and stated that her abdomen hit the steering wheel. She was complaining of some mild lower abdominal pain which was non-radiating. She denied any associated leakage of fluid, vaginal bleeding, or contractions. She reported decreased fetal movement since the accident. 

A Focused assessment with sonography in trauma (FAST) scan noted the fetus in cephalic presentation with positive fetal heart tones. The placenta was posterior and there were no obvious placental abnormalities noted. The patient's physical exam was otherwise normal. The patient was noted to have knee pain and tenderness on exam and was sent for an x-ray, which was normal. The biophysical profile was also completed and reassuring prior to transfer to labor and delivery for monitoring. A computerized tomography (CT) scan of the neck noted no acute traumatic pathology. The labs were normal. The intracranial anatomy was cleared.

She reported mild intermittent contractions every 30 minutes. She reported good fetal movement. The patient continued to do well and felt no contractions following admission. The reactive tracing was noted of the fetus and reassuring. The patient had a normal hemoglobin and hematocrit, and her fetal hemoglobin stain was negative. She was Rhesus (Rh) positive (+). She was obstetrically cleared for discharge to be seen as an outpatient. 

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.

Based upon a review of the medical records, and the recommendations of the American College of Obstetrics and Gynecology (ACOG), there would have been no medical necessity for acute inpatient level of care admission. There was no cervical exam on admission to document the cervix. However, given preterm contractions, a plan was made for fetal monitoring and ultrasound. The ultrasound and monitoring were reported as normal and reassuring with a singleton gestation that was normally grown with normal fluid with a biophysical profile (BPP) of 8/8 and reactive non-stress test (NST). Contractions were every 10 minutes, and no cervical change or labor was reported. Given gestational age and motor vehicle accident as the causation, magnesium was not indicated and given lack of labor, steroids were deferred. 

This recommendation agrees with the recommendations of the American College of Obstetricians and Gynecologists (ACOG). There was no evidence of preterm labor as there was no cervical change documented. If a cervical change had been detected, steroids generally would have been administered and magnesium for completion of the steroids would generally be considered for 24 hours. Given the review of the ACOG recommendations, there was no medical necessity for admission to an acute inpatient level of care. 

Therefore, the requested health service/treatment of inpatient stay was not medically necessary for this patient.