Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth - fetal hydronephrosis and non-immune hydrops. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient emergency admission. 
The denial is upheld.

The patient is a gravida (G)2 para (P)1 who presented at 36-2/7 weeks after being sent to labor and delivery for induction of labor due to fetal hydronephrosis and non-immune hydrops. The patient was noted have a prenatal course that was notable for hyperemesis which had resolved. The patient's prior pregnancy history was noted for a term vaginal delivery resulting in a 7 pound 11-1/2 ounce infant complicated by gestational diabetes.

The physical exam was noted to be normal. The patient underwent ultrasound which noted a vertex presentation with a posterior placenta and an estimated fetal weight of 6 pounds (lbs.) 9 ounces (oz.) at 2974 grams at the 63rd percentile. The cervical exam was closed, long and -3. Patient was admitted to labor and delivery for a plan of delivery and had a group B strep screen sent. She was started on penicillin, as the group B strep status was unknown. She was also ordered for Celestone for fetal lung maturity. She was Rhesus factor positive (Rh+). Intravenous (IV) fluid was started with dextrose five percent lactated ringers (D5 LR) at 125 cubic centimeters (cc) and sequential compression devices were placed on the patient's lower extremities. Induction was planned with vaginal Cytotec. Following admission, there was concern that the patient was noted to have right hydronephrosis and concern for developing fetal hydrops. There was concern that the baby would require a level III neonatal intensive care unit for stabilization and the patient was transferred to another facility for delivery at that facility. During the time in the hospital, the patient had stable vital signs with normal blood pressure of 113/72 with a heart rate of 85 and respiratory rate of 20. Oxygen saturation was 100% on room air.
The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld.

Based upon a review of the medical records, the recommendations of the American College of Obstetricians and Gynecologists (ACOG) and the peer reviewed literature, there would have been no medical necessity for acute inpatient level of care admission for presentation for induction of labor. In this case, the patient was noted to have a singleton gestation at 36-2/7 weeks complicated by hydronephrosis and possible development of non-immune hydrops. The patient had been sent for an induction of labor with a long and closed cervix. Given she was less than 37 weeks, a course of steroids were planned given prematurity based upon the Antenatal Late Preterm Steroids (ALPS) trial. She was also started on IV fluid and a plan was made for induction. Fetal monitoring was started and reassuring. However, given the concern for hydrops, the induction was canceled at the facility and the patient was transferred to an outside hospital for plan of induction and delivery. Thus, the care that was rendered would consist of labs for group B strep (GBS), starting penicillin given unknown GBS status, starting an IV and running D5LR fluid, application of sequential compression devices, fetal monitoring and administration of steroids. The patient started on IV D5LR and Celestone for steroids only and was then transferred for plan of delivery owing to the concern for hydrops and there was no further care rendered. Given this presentation, the type of care rendered would be within the scope of care for lower level of care status but would not meet medical necessity for admission to acute inpatient level of care.