Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bile duct obstruction 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial was upheld. 

This is female over 30 weeks gestation with a history of intrauterine growth restriction. She presented to the Emergency Department with complaints of itchiness on the abdomen, upper thighs, and buttocks. Her vital signs were normal. Liver function tests and uric acid level were elevated. Platelet level was low consistent with a similar result in early pregnancy. She was admitted for an obstruction of the bile duct. The plan was to administer two doses of intramuscular betamethasone, administer ursodiol twice a day, and delivery at if bile acids are positive for cholestasis. The patient would be tested twice weekly on an outpatient basis. The non-stress test was reassuring. The 24-hour urine result was 130. Liver function test levels decreased. 

Cholestasis (ICP) is characterized by pruritus and an elevation in serum bile acid levels, typically developing in the second and/or third trimester and rapidly resolving after delivery. Pruritus, which may be intolerable, is often generalized but predominates on the palms and the soles of the feet and is worse at night. 

The diagnosis of ICP is based upon the presence of pruritus associated with elevated total serum bile acid levels, elevated aminotransferases, or both, and the absence of diseases that may produce similar laboratory findings and symptoms. The differential diagnosis of pruritus and hepatic dysfunction in pregnancy include HELLP syndrome, preeclampsia with severe features, acute fatty liver of pregnancy. This patient did not have any of these diagnoses.  It is unclear why this patient was admitted. There was no elevation in her blood pressure. No protein in urine. Her liver function tests were minimally elevated. Admission is not necessary to rule out cholestasis. Her membranes were not ruptured. The fetal heart rate was reactive and there was no contraction. 
MCG guidelines list some of the following clinical indication for antepartum admission: Condition requiring premature delivery, Delivery, Fetal distress or demise, Preterm labor and positive fFN, Significant maternal disease, infection or comorbidity as cause, Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accreta, Tocolytic therapy that requires inpatient care, Complications of tocolytic treatment. 

This patient did not have any of the above. The only reason the patient was admitted was to rule out cholestasis. And as mentioned above, admission is not needed for that purpose. 

Based on the above, the patient could have been observed and once the provider ascertained that both mother and fetus were stable, the patient could have been sent home to be followed closely as an outpatient. 

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

The inpatient hospital admission is considered medically necessary for this patient. 

Based on the above, the medical necessity for the inpatient hospital services is not substantiated. The insurer's denial is upheld.