Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy / Childbirth 
Treatment: Inpatient Hospital Stay 

The insurer denied the Inpatient Hospital Stay. The determination is upheld. 

The patient is a gravida (G) 2 para (P) 0 abortus (AB) 1 who presented to the hospital at 29-5/7 weeks' gestation with a diamniotic/dichorionic twin gestation. The patient was reporting constant abdominal tightening over the past day. She denied leakage of fluid, vaginal bleeding or decreased fetal movement. The patient's history was noted for one prior spontaneous miscarriage and then she had an in vitro fertilization (IVF) pregnancy with embryo transfer. She denied any complications. The presentation vital signs were stable and she was afebrile. The fetal heart rate for twin A was in the 135 baseline with moderate variability, positive accelerations, and twin B was in the 140s with moderate variability and both were reactive for gestational age. The uterus noted irregular contractions with 3 contractions in a 45 minute period for approximately every 15 minutes. A vaginal exam was deferred. 

An ultrasound noted a cervical length to be 3.8-4.3 centimeters (cm) long and the deepest vertical pocket for baby A was 5.12 cm and baby B was 4.55 cm. The patient was assessed at 29 weeks and 5 days with abdominal tightening and a normal and reassuring cervical length of 3.8-4.3 with irregular contractions. The patient had a urinalysis and urine culture sent and intravenous (IV) hydration boluses with lactated Ringer's was given. Contractions were monitored. The patient continued to have reassuring fetal testing. She had pain reported of 3 out of 10 at the time of contractions. The patient's vital signs were normal. She was seen and noted to have preterm contractions every 6-8 minutes that did not resolve with 2 liters (L) of lactated Ringer's. 

The patient continued to have a normal cervical length of 3.52 cm 4 hours after observation. Her urinalysis was negative. The patient had a reactive tracing for both baby A and baby B that was reassuring. She was admitted to labor and delivery with continuous electronic fetal monitoring and IV hydration. Magnesium sulfate was started and betamethasone series was planned. Ampicillin was also planned. The patient was planned for magnesium and 6 grams (g) for contractions and neuroprotection. The patient was anxious asking questions about possible preterm delivery with all questions answered. She remained stable overnight and her contractions had spaced out and became irregular every 20-30 minutes with only a mild feeling of discomfort. She denied a fever, vaginal bleeding or leakage of fluid. Her vital signs remained stable. The patient had refused ampicillin, betamethasone and group B strep testing despite counseling on fetal risks. The patient was on magnesium sulfate for fetal nerve protection. She was seen at and reported no further contractions. The patient had continued to refuse betamethasone for fetal lung maturity and ampicillin unless she was going to deliver on that day and it was absolutely necessary. The risks benefits and alternatives were explained to the patient. The patient reported that she was not delivering vaginally and would not need ampicillin. Given that the patient had no contractions, magnesium was discontinued at that time. The patient remained stable without complications and reassuring fetal testing and was discharged to home. Outpatient follow-up was scheduled. At issue is the medical necessity of an inpatient stay. 

Based upon a review of the medical records, the recommendations of the American College of Obstetrics and Gynecology (ACOG) and the Milliman Care Guidelines (MCG) Guideline entitled "Preterm Labor, Threatened, there was no medical necessity for acute inpatient level of care admission. In this case, the patient was noted to have a diamniotic/dichorionic twin gestation at 29 5/7 weeks gestation with threatened preterm labor. There was no cervical exam on admission to document the cervix by the physician. The transvaginal cervical length was normal and had no significant change noted. However, given preterm contractions in the absence of cervical change, a plan was made for ampicillin, magnesium and steroids. The ultrasound and fetal monitoring were reported as normal and reassuring with a twin gestation with normal fluid. The patient completed a 12 hour window of magnesium sulfate without complications for neuroprotection. There was refusal of two doses of betamethasone for fetal lung maturity or ampicillin. The patient had a trial of tocolysis that was successful and without complications with the magnesium sulfate. In this case, the care rendered would have been appropriate at a lower level of care. The MCG Care Guideline entitled "Preterm Labor, Threatened" would support admission to acute inpatient level of care for the following: 1) Condition requiring premature delivery (eg, preterm premature rupture of membranes with nonreassuring fetal status, chorioamnionitis - This was not present in this case 2) Fetal distress or demise - This was not present and the fetal status was reassuring 3) Preterm prelabor rupture of membranes - This was not present
4) Significant maternal disease (eg, infection) identified (eg, pyelonephritis, pneumonia) that requires inpatient treatment (eg, IV antibiotics, close monitoring) - This was not present as the patient had no medical conditions 5) Vaginal bleeding (eg, placental previa, vasa previa, placenta accreta) - This was not present 6) Complications of tocolytic treatment (eg, pulmonary edema, hypotension) - There were no complications of tocolysis in this case. 7) Continued fetal monitoring that requires inpatient care (ie, needed beyond observation care time frame (eg, 24 hours)) - This was not present in this case 8) Tocolytic therapy needed that requires inpatient care (ie, needed beyond observation care time frame (eg, 24 hours) - This was not present in this case. There was no need for prolonged care. 9) Inability to stop preterm labor - This was not present as the patient was noted to have no preterm labor or contractions after tocolysis. In this case, none of the criteria for admission to acute inpatient level of care were supported based upon a review of the medical records and the MCG Care Guideline. 

These recommendations are in agreement with the recommendations of the American College of Obstetricians and Gynecologists (ACOG). In this case, the patient was admitted preterm at 29 5/7 weeks with threatened preterm labor without documented cervical change in the setting of contractions. There was no evidence of preterm labor as there was no cervical change documented. The standard of care would be observation for cervical change. Preterm labor was not present as there was no cervical change documented in the charting by the physician. If cervical change had been detected, steroids would be administered and magnesium for completion of the steroids would be considered for 24 hours. This may be continued to achieve 48 hours of tocolysis to complete steroids. In this case, there was no cervical change documented. In this case, the use of magnesium would not be supported as medically necessary. ACOG states the following regarding this practice: "Tocolytic therapy may provide short-term prolongation of pregnancy, enabling the administration of antenatal corticosteroids and magnesium sulfate for neuroprotection, as well as transport, if indicated, to a tertiary facility. However, no evidence exists that tocolytic therapy has any direct favorable effect on neonatal outcomes or that any prolongation of pregnancy afforded by tocolytics actually translates into statistically significant neonatal benefit." Thus, this would not be supported and this was not medically necessary for tocolysis as used in this case. 

Given the review of the ACOG recommendations and the MCG Care Guideline, there was no medical necessity for admission to acute inpatient level of care. The patient had no signs or symptoms of preterm labor. She was on magnesium but this was not indicated and could have been discontinued as steroids were completed.