Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth- Other-contractions.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient at the time of service was a  gravida2 para0 abortion1 who presented at 38-0/7 weeks gestation with contractions. The patient was contracting every 10-15 minutes since the previous afternoon. She denied leakage of fluid or vaginal bleeding. Fetal movement was present. Prenatal care was noted for in vitro fertilization (IVF) pregnancy. The patient was 1 centimeter (cm) dilated, 100% effaced, and negative (-)1 station. Breech presentation was noted, and the cervical length was 1.7 cm. She had an elevated glucola (screening test for gestational diabetes) with normal 3 hour glucose tolerance test (GTT).  She was noted to have a singleton intrauterine pregnancy (IUP) with breech presentation and fundal placenta and amniotic fluid index (AFI) of 8 cm. The estimated fetal weight was 2591 grams by ultrasound. The fetal heart tones were reassuring and Category I and every 7-9 hours. The patient was discharged to home with a plan for return at a later date for cesarean delivery.

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  "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 singleton gestation at 38 weeks gestation with threatened labor. There was a cervical exam on admission to document the cervix by the physician. However, given lack of cervical change and a breech presentation, the patient was scheduled for cesarean at 39 weeks gestation. She had no ongoing cervical change or active labor documented. The ultrasound and monitoring were reported as normal and reassuring with a singleton gestation that was normally grown with normal fluid. The fetal monitoring was Category I. Given the gestational age at presentation, steroids, magnesium and tocolysis would not be indicated in this case. In this case, the care rendered would have been appropriate at a lower level of care.

None of the criteria for admission to acute inpatient level of care were supported based upon review of the medical records and the MCG Care Guideline. These recommendations agree with the recommendations of ACOG. In this case, the member was admitted at near term with threatened labor without documented cervical change in the setting of contractions. There was no evidence of active labor. The standard of care would be observation at a lower level of care for cervical change. Given the gestational age, there is no indication for steroids, tocolysis (also called anti-contraction medications or labor suppressants), or magnesium tocolysis. ACOG states the following: "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 given the gestational age in this setting.